LIBRARY OF CONGRESS, 



Shelf 






UNITED STATES OF AMERIC 



1 



THE 



Life Insurance Examiner. 



A PRACTICAL TREATISE 



UPON 



Medical Examinations for Life Insurance, 



jp 



BY 



CHARLES F; STILLMAN, M. S., M. D. 



Medical Examiner for the Mutual Life Insurance Company at the General Agency for 
the City of New York. 

Examining Surgeon of the Travelers Insurance Company of Hartford, Conn., for the 

City of New York. 



JliN ^ 

XL 



THE SPECTATOR COMPANY, 
16 Dey Street. 

1888. 



*£ 



To RICHARD A. McCURDY, Esq., this book is respectfully 
dedicated as a token of personal esteem by 

THE A UTHOR. 



Copyright by The Spectator Company, 1887. 



PREFACE 



IT is a natural inquiry on the part of a newly appointed Medical 
Examiner: " How shall I most satisfactorily perform the duties of 

my position ?" 

The function of a medical college is to teach principles, and the object 
of this book is to apply those principles to the requirements of the Life 
Insurance Examiner. 

In the present work the author aims to present a concise, practical 
manual, which will enable even the beginner in life insurance examinations 
to conduct an examination satisfactorily to the company by whom he is 
employed — to the applicant and to himself — and it is intended to be a 
systematic and complete treatise upon the subject of life insurance exam- 
inations. It represents the results of many years of practical experience in 
the department of which it treats, and the author takes pleasure in acknowl- 
edging the valuab.e services of Dr. George D. Clift in its preparation. 



INTRODUCTION 



IN the early days of life insurance in this country, very few questions 
were propounded by the Medical Examiner, all questions referring to 
the family and personal history of the applicant being answered by the 
agent, who filled out the application, so that the Medical Examiner had very 
little more to do than inspect the applicant. But during recent years, the 
Examiner has been obliged to answer more of the questions contained in the 
application, until now, at least in most of the large companies, the Examiner 
is required to fill up all the questions relating to the application, except 
the mere request for insurance and the form of policy desired. 

Every application does, or should, contain the question whether the 
applicant has been previously rejected or postponed by any other company, 
and if, upon examining an application, the Medical Examiner does not find 
this question, he should at once propound it to the applicant ; and even if 
the question be found upon the application, and is answered, he should 
still observe the rule to propound the question before the examination is 
commenced, since agents, in writing an application, do not use sufficient 
care in regard to this question, and if it be incorrectly answered, it renders 
the policy void at the option of the company. 

Then again, the fact of previous postponement or rejection should 
cause extra care in examination, it being to the Examiner's interest to dis- 
cover, if possible, any cause for rejection or postponement which has been 
deemed by any other Examiner of sufficient importance to cause such 
action ; it being understood, however, that the applicant, if no other 
reasonable cause for rejection or postponement can be found, is as much 
entitled to his insurance under the present examination as if he had not 
been previously rejected or postponed. 

Be sure that the person who appears before you for examination is the 
individual who has signed the application. Never make an examination 
unless the signed application is before you, for several reasons. If signed 
afterwards, and not in your presence, a totally different person may be 
substituted for the one you have examined. It is, therefore, to avoid all 
chance of substitution, better to see an applicant write his name in the 
Examiner's presence, the Examiner then to compare the signature so written 
with the signature in the application. Some companies now carry this idea 
so far as to make it unnecessary for the Examiner to write the applicant's 
name at all, the applicant writing his own name three times, once on the 
application for insurance, and twice before the Medical Examiner — once 
his full name, and the second time his usual signature, to which the 



The Life Insurance Examiner. 



Examiner then becomes witness. If, upon inspection, it being understood 
that the Examiner has no personal knowledge of the applicant, the sig- 
natures executed before him correspond with the signatures before the 
examination, the examination itself should then be proceeded with. 

Owing to the competition now existing between the various life insur- 
ance companies, and the difficulty with which desirable applications are 
secured, it becomes a matter of paramount importance for the physician to 
so examine the applicant as to cause him to be friendly toward the com- 
pany, and not to feel that he has been unduly or unnecessarily subjected to 
harsh or unbusiness-like treatment during the examination. 

In many cases it is only by the most persistent solicitation, and after 
repeated and determined efforts on the part of the solicitor, that a man can 
be induced to apply for examination, and a genial manner on the part of 
the Examiner is of great importance, especially if the applicant is appearing 
for examination for the first time, as he is then more apt to be nervous and 
excited, not knowing but that some imperfections will be found in his 
organism before unknown to him, which will not only debar him from insur- 
ance, but will necessitate his taking medical advice from his family physician. 

Another point which cannot be too strongly impressed upon the Ex- 
aminer is that as an official of the company he represents, and paid as he is 
for his services by that company, he should retain such information as he 
elicits about an applicant for the company's own benefit ; and even if he be 
the family physician of the applicant, he should remember that any point 
discovered by him during such examination is the property of the company, 
is paid for by the company, and is not the property of the applicant. 

The Examiner should also remember that it is the business of an agent 
to procure the acceptance of a risk, if possible, and he should refuse to give 
an agent any information about an applicant unless authorized to do so in 
any particular case by the Medical Directors of the company for which he 
is examining. The neglect of this rule not only subjects the Medical 
Directory to annoyance from the agents, but also very frequently from the 
applicant himself, in case of rejection. On the other hand, the Examiner 
should remember that the applicant is entitled to his insurance in case he 
does not fall below the standard of excellence established by the company. 
But again it should be impressed upon him that no information relative to 
the case should be afforded either to applicant or to agent, for the latter 
has the power to apply directly to the home office of every company to 
learn the cause of postponement or rejection ; and the responsibility of 
affording him information in such a case, or of affording the applicant 
information, should rest entirely with the executive department of the com- 
pany for which the Examiner is acting, and not with the Examiner himself. 



PART I. 

LIFE INSURANCE FORMALITIES. 



AS the Medical Examiner should make himself familiar with all the 
questions put to the insurance candidate, we insert the following 
list, classified from the forms used by six of the prominent insurance 
companies. 

MEDICAL EXAMINER'S REPORT. 
Identification. 

SIGNATURE. — (Sign in the presence of the Medical Examiner.) Signa- 
ture of the person examined in full. Did the applicant sign the above in 
your presence? Signature of the party or parties for whose benefit the in- 
surance is to be effected (write in full). 

Residence. — Country. State. County. Town. Place of business. 
P. O. Address. Former residence. Is the risk affected by the place of 
residence? Where has the party resided (during summer and winter) dur- 
ing the last ten years ? 

Identification. — (The examining physician is requested to satisfy 
himself in all cases as to the identity of the party being examined.) Do 
you know the applicant to be the person described in the application? 
Is he known to you? How long? How well? Mention some mark of 
identification. Place of birth. Date ol birth. 

Environment. 

OCCUPATION. — Is there anything seriously unsanitary in the occupa- 
tion, or in the residence or place of business? Does- the person contem- 
plate a change of residence? If so, when, to what place, and why? (That 
is, whether for purposes of business, health or pleasure.) Has he had yel- 
low fever? If not, does yellow fever ever prevail where applicant re- 
sides ? State how long he has lived in present locality ; how long and when, 
in other localities similarly exposed ? Is he thoroughly acclimatized. 

Is the risk affected by anything in his residence or occupation ? (State 
definitely ; if more than one occupation, state all of them. If on railroad, 
say how employed.) Former occupation, if recently changed. Is applicant 
in any way engaged in the sale of malt or alcoholic liquors ? Is there any 
intention of changing residence or occupation? If so, state intention. 
Has change of climate ever been sought or advised for the benefit of 



The Life Insurance Examiner. 



your health? Have you ever resided out of the United States? If so, 
where and for what period ? Was it on account of ill health ? 

In giving the occupation of the party, it is not sufficient to state (for 
example) that he is a merchant, mechanic or clerk, but the particular branch 
of business or trade must be specified, and full particulars given where the 
occupation is in any way hazardous. Does the party agree not to reside or 
travel within the tropics, and not to engage in blasting, mining, sub-marine 
operations, aeronautic ascensions, or in service upon any railroad train, or 
in switching or coupling cars, or upon any steam or other vessel, during the 
next two years following the date of any policy issued hereon, without first 
obtaining the written permission of this company ? 

Has the applicant ever changed his residence or traveled on account of 
his health, or has his health been affected by any Southern or foreign resi- 
dence ? 

Is applicant married or single ? 

Physique. 
Age? Temperament? Race or nationality ? Complexion? Weight 
(coat and vest off)? Height (in shoes)? Girth of chest, under vest, 
forced expiration ? Same, forced inspiration ? Girth of abdomen, at waist- 
band of trousers? If under or over-weight, is this feature an individual or 
family trait? Any deformity ? Any injury or loss of limb? (If of lower 
extremity, state whether thigh or leg amputation.) Any rupture ? If so, 
is truss worn ? State the kind of hernia ? Figure ? Color of hair and 
eyes ? Has the weight recently increased or diminished — and from what 
cause ? Which parent does he resemble most in general temperament and 
constitution ? Can you answer from personal knowledge ? Does his 
appearance indicate health and vigor? 

Hereditary Influences. 

Inquire of applicant, and set down below, as particularly as you can, 
the vital statistics of the family. 

Family Record of Applicant. 





Living. Dead. 




Age? 


Health? Age? ! Spec g^ a ? se ° f 


How Long Sick ? 


Father 






' 


Father's father 

Father's mother 

Mother 








Mother's father . . . 
Mother's mother. . . 





The Life Insurance Examiner. 





Living. 


Dead. 


% 


Age? 


Health ? 


Age? 


Specific Cause of 
Death ? 


How Long Sick ? 


Brothers 
















Sisters 

















Any consumption, insanity, constitutional or hereditary disease in the 
family, other than appears above — i. e., among uncles or aunts ? If so, state 
particulars. 

Have any two members of the family, grandparents included, had con- 
sumption, cancer, paralysis or apoplexy, disease of heart or kidneys ? 

The Medical Examiner will please obtain from the party, as fully as 
possible, answers in detail. In giving cause of death, avoid all indefinite 
terms, as "General Debility," "Change of Life," "Fever," "Dropsy," 
"Exposure " or " Accident." If the word " childbirth " is used, state how 
long after delivery death occurred, and whether there were any symptoms 
of disease of the lungs. 

Has the party any predisposition, either hereditary or acquired, to any 
constitutional diseases, such as consumption, rheumatism, syphilis, insanity, 
gout, scrofula? 

Nutrition and Diathesis. 

Any history of malaria, rheumatism, gout, syphilis, tuberculosis, 
scrofula, cancer, tumors, glandular swellings or dropsy? Where answers 
are "yes " here and below, state particulars — i. e., date, duration, severity 
and results of the affection. Anything unfavorable in the general appear- 
ance, such as sickly aspect, or unduly full habit, or apparent proneness to 
fatty degeneration ? Is there any evidence of former illness ? 



The Skin. 

Any skin eruption, sores or ulcers ; any history of skin disease or 
vestiges of the same ? Has he had erysipelas, carbuncle, boils ? 

Nervous System. 

Any history of severe headaches, vertigo, loss of consciousness, con- 
vulsions, tumors, epilepsy, delirium tremens, paralysis, apoplexy, nervous 
exhaustion, mental derangement or spinal disease? Any present derange- 
ment of function, or suspicion of any lesion ? 



io The Life Insurance Examiner. 

Organs of Special Sense. 

Any history of otorrhcea or otitis ? 

Any serious impairment of sight or hearing? 

Respiratory Organs. 

Number of respirations per minute? Is the character of the respira- 
tions other than full, easy, distinct and regular ? Is there any history of 
haemoptysis or spitting of blood, chronic catarrh, hoarseness or cough, 
shortness of breath, asthma, bronchitis, pneumonia, pleurisy? 

Is there present impairment of function, or any abnormality, discover- 
able by means of physical diagnosis ? 

Blood Vessels. 

What is the rate and other qualities of the pulse? Count at least a 
minute. Is it intermittent or irregular? If the applicant is excited, wait 
and secure the normal rate. Is there any indication present of any disease 
of the heart or blood vessels ? Any abnormality discoverable by ausculta- 
tion or percussion ? Any history of sunstroke, faintings, palpitations or 
cardiac pains; of varicose veins or bleeding piles; or any suspicion of 
atheroma or aneurism? 

Alimentary Canal. 

Any history of difficulty in swallowing, dyspepsia, chronic diarrhoea or 
dysentery, constipation, colic, jaundice or liver disorder, fistula in ano ? 
Any present impairment of function or trace of organic disease ? 

Urinary Organs. 

Specific gravity and reaction of the urine ? The Examiner must have 
personal knowledge that the urine was voided by the applicant. Does it 
contain albumen? Employ the most accurate tests. Sugar? Examine 
for sugar carefully when the specific gravity is over 1.025. Color and 
appearance of urine? Frequency of micturition? Quantity voided in 
the twenty-four hours ? Nature and amount of sediment ? 

Microscopical examination. Any casts? Blood? Pus? Crystals? 
Other elements ? The microscopical examination is omitted unless required 
by the company in special cases, or when the policy is for an extraordinary 
amount. 

Is there any history of gravel, calculus, cystitis, nephritis, dropsy, 
diabetes ? 

Organs of Generation. 

Any history of venereal disease, stricture, prostatitis, enlarged pros- 
tate ? Females. — Any menstrual disorder, history of uterine or ovarian 
disease, abortion or difficult labors ? Is applicant now pregnant ? Has she 
borne children; if so, how recently? Has she passed the climacteric ? 



The Life Insurance Examiner. u 

General Health Record. 

Any history of serious illness, injury or deformity, not alluded to 
above ? Are you satisfied that there is nothing in his physical condition, 
habits, personal or family history, not distinctly set forth, tending to shorten 
life? Is the applicant insured in this or any other companies? Has any 
proposition, negotiation or examination for life insurance been made in this 
or any other company or association, on which a policy has not been issued ; 
if so, when and in what company ? 

Has applicant had smallpox or varioloid ? Date of successful vaccina- 
tion ? Does scar exist ? 

Personal Habits. 

Does he drink wine, spirits or malt liquors daily or habitually? If so, 
to what extent? Former habit of drinking intoxicating beverages? Does 
he now or has he ever used opium, chloral, tobacco, or other narcotics? 
Does he use tobacco to excess ? 

Are there any evidences of impaired health or constitution from the 
use of stimulants or narcotics ? 

Medical Adviser, etc. 

Name and address of applicant's regular physician ; or, if there be 
none such, that of the physician last consulted, with the nature of the ill- 
ness. Does the applicant expressly waive all provisions of law forbidding 
any physician who has attended him from disclosing all information thereby 
acquired? Do you desire any information from his medical adviser; if so, 
procure and submit it with this report. 

Name and residence of an intimate friend, who may be referred to for 
information. 

Remarks. 

(Here note any circumstances affecting the risk which do not appear in 
the foregoing answers.) • 

Opinion. 

Compared with the average of lives of the same age and sex, does 
the " expectation of life" in this applicant seem to you " first class " or 
< 4 fair" only, or "doubtful," or "bad?" If you were yourself in the busi- 
ness, would you grant this subject a life policy ? (Answer conscientiously, 
independent of set rules and instructions; your own, honest, individual 
opinion is what is wanted.) If not for life, for what term of years would 
you issue a policy ? 

Signatures, etc. 

Append the signatures and addresses of both applicant and Medical 
Examiner, with exact dates. 



12 The Life Insurance Examiner. 

Additional Female Certificate. 

In case the candidate is a woman, the following additional questions 
are required : 

Name? Residence? Is she well formed; and do her weight, height 
and general appearance indicate a healthy person ? Is she now pregnant? 
Are the functions of the uterine system in a healthy condition? Is any 
disease of the breast suspected ; if so, what? Has she ever had prolapsus 
uteri, ovarian disease, or any disease of the genito-urinary organs? Are 
there tumors suspected in the womb or other part of the body? Has she 
ever miscarried ? If so, how many times and under what circumstances? 
If she has borne children, how many, and were the labors natural and with- 
out serious results? Are you acquainted with any facts affecting her health 
not included in the above questions? Do you consider her safely insura- 
ble and recommend that a policy of insurance be granted ? Date. Signa- 
tures. 

(Agents' Report and Instructions to Agents, see Appendix.) 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

(Revised from the rules observed by the prominent companies.) 

General Rules. 

1. The company's latest issue of blank form of application must be 
used in all cases. Examine it carefully, and see that every question is cor- 
rectly and definitely answered. 

2. Conduct your examination in private, and not in the presence of the 
agent, or of others ; except in the case of females, when it is often prudent 
to have your own witness present. 

3. Applicants must be examined in the places where they reside or do 
business, unless otherwise desirable, and by the Examiner regularly ap- 
pointed and accredited to such place. When the Medical Examiner is 
himself the applicant, he must be examined by another Medical Examiner 
regularly appointed in the same or in a neighboring place. 

4. Applicants cannot be examined by Medical Examiners who are 
either their relatives or who may be directly or indirectly beneficiaries 
under the policy. 

5. Make your report full and precise. Such report has to serve the 
Medical Detectors at the home office as the basis of their professional judg- 
ment on the risk. 

6. The Medical Examiner's report should be free from alterations, in- 
terlineations or erasure*. When unavoidable, the same must be duly at- 
tested by the party entitled to make them, with date of such attestation. 

7. Medical Examinations, to be accepted, must have been made within 
thirty days prior to the receipt of the application at the home office. 



The Life Insurance Examiner. 13 

8. Particular attention should be paid to writing out the full name of 
the person examined. 

9. He must date his examination the day it was made. 

10. The company holds the Medical Examiner responsible for the 
identification of applicants, and he is instructed to make no examination 
unless the applicant is personally known or satisfactorily introduced to him. 
The same rule applies to persons presented for examination for certificates 
of health, which, in all cases, must be paid for by the applicant and must 
not be charged to the company. 

11. A Medical Examiner who removes from the district to which he 
has been accredited forfeits his appointment. He may, at the discretion of 
the company, be reappointed for the district to which he has removed, pro- 
vided there is a vacancy at that point. 

12. An Examiner who signs as witness to an applicant's signature 
should state the reason therefor, and whether he has any interest in the 
transaction. 

13. The home office expects the Examiner to notify it in every case 
where a policyholder may be violating the terms of the policy by vicious 
habits, or otherwise in any way tending to shorten life. Thus unjust claims 
may be avoided. 

14. The Examiner should report any local cause of disease, which 
makes a particular residence unhealthy, and also whether there is anything 
in the occupation rendering life insecure. Persons not infrequently change 
their residence and business for sanitary reasons. Such reasons must be 
investigated. 

15. If the applicant has ever applied, or been examined, for life insur- 
ance, and no policy issued, explanation of the reason for such non-issue of 
policy must be given, with date of rejection and name of company. 

16. A Medical Examiner may solicit applications for insurance, and 
participate in the commissions accruing therefrom under the rules of each 
company, but he must, in every such instance, submit the applicant to 
another regularly appointed Examiner for examination. It is manifestly 
improper that he should act as Examiner and agent at the same time. 

17. Where the application is from §20,000 to $30,000 or over, the 
applicant must be examined by two regular Examiners. Two large com- 
panies require three Examiners for amounts over $50,000. 

18. The Medical Examiner's relation to the applicant for life insurance 
is opposite to that which he occupies in his professional capacity. In the 
latter case the patient exposes his infirmities, and even intensifies them ; 
the applicant for life insurance, on the other hand, may desire to lessen 
their importance or conceal their existence. 

19. The Medical Examiner is che guardian of the interests of the com- 
pany. He is expected to furnish the company, on its appropriate blanks, 
an explicit and truthful statement of the age and physical condition of the 



14 The Life Insurance Examiner. 

person proposed for insurance, and to revise the statements made in the 
application, with a view of demonstrating their correctness. For this 
reason he receives a fee, whether the applicant be accepted or rejected. 

20. He should be careful to give a clear statement of the circumstances 
appertaining to each case. If any disease or disorder has occurred, name 
it specifically, avoiding such phrases as u urinary trouble," " kidney diffi- 
culty," u throat disorder," " complications," etc. These terms, conveying 
no precise information, produce an unfavorable impression as to the risk, 
and cause additional correspondence and delay. 

Physique. 

1. In the matter of physical examination be thorough, no matter how 
sound the candidate may appear, nor how well you may know him. 

2. The Examiner should notice whether the age given corresponds 
with the appearance of the person, and when marks of premature decay 
are present, should report them. He should also notice whether the person 
be erect, well-formed and of healthful aspect, and whether the height be in 
proportion to the weight. 

3. If the applicant be over the standard weight, state whether it is 
caused by fat or by development of bone and muscles, and whether the 
party is of an active or sedentary habit. If underweight, it is important to 
know whether the tissues are firm and healthy, or otherwise. In either 
case, find out if the peculiarity is or is not a family characteristic. 

4. Defects of vision or hearing may be of serious import, either them- 
selves impairing the risk or indicating disease of vital organs. 

5. Any injury, mutilation or deformity must be reported. 

Hereditary Influences. 

1. The family record is often carelessly reported, and the frequency 
with which parents, brothers or sisters die of " old age," " exposure," " child 
birth," "change of life," " don't know," and similar ambiguous causes of 
death, has made each company desirous of getting specific information, un- 
embarrassed by vague or unscientific terms, upon these vital points. Try 
to elicit the specific disease causing death, especially when there may be a 
suspicion of consumption. State whether phthisis was or was not an ele- 
ment of a fatal illness. 

2. In some cases the applicant may really be ignorant of the exact 
ages or causes of death in the case of near relatives. If so, state the facts 
plainly. 

3. Predisposition to disease is regarded under two aspects: 

First. When the family history is such that the person may be con- 
sidered predisposed to the disease of which his parents died — as, for in- 
stance, when the death of both was caused by consumption, insanity or so- 
called scrofulous disease. 



The Life Insurance Examiner. 



Second. When one parent and a number of brothers and sisters, or 
other relatives, have so died, conjoined with personal traces of the disease. 

4. The cases where one parent has died of a disease, the predisposition 
to which in the offspring may- be hereditary, the person, by reason of age, 
conformation, health and occupation, with an affinity to the healthy parent, 
may be fairly entitled to a limited form of policy. 

5. Observe, also, hereditary or acquired tendencies to other diseases, 
especially rheumatism, heart disease, gout, cancer, kidney disease, insanity, 
syphilis, paralysis, apoplexy and nervous diseases, and furthermore, the 
general family tendency to longevity or early deaths. 

General Health Record. 

1. In the matter of personal history, ask specifically the questions 
necessary to cover the points of inquiry called for by the blank form, and 
do not accept in reply any general negative — such as, " Oh, I have never 
been sick." Many occurrences bearing on assurabilify, but which do not 
constitute serious disease, such as an haemoptysis, an otorrhcea, a fistula, or 
a stricture, are often forgotten by candidates until specifically inquired about. 

2. A direct question should be asked, embracing all such diseases as 
may be omitted in the form, or known to the applicant by other names. 
Many diseases, like malarial and typhoid fevers, may leave serious impres- 
sions on the constitution, or, on the contrary, may tend to improve the risk. 

3. In many instances, predisposition to disease may be acquired from 
habits of life, occupation, exposure, accidents, unhealthy residence, previous 
attacks of disease, etc. It is the duty of the Medical Examiner to make a 
close examination of all the facts bearing upon such cases, or to state in the 
application, or in a private letter, to the medical officers, such modifying 
circumstances. 

Personal Habits. 

1. The regular or occasional use of intoxicating liquors, tobacco or nar- 
cotics needs special investigation, as experience has proved that habits of 
drinking and the use of narcotics have more influence in determining the 
probability of life than any other adverse factor in the problem of life in- 
surance^ 

2. The applicant's habits of using alcoholic stimulants, opium, tobacco, 
etc., should be definitely ascertained, and in stating them in your report, 
avoid the use of such words as " moderate," " occasional " and * temperate." 
Where their daily or frequent use is suspected, assure yourself that the 
stomach, liver, kidneys and nervous system are free from evidences of injury. 

3. In the matter of habitual indulgence in alcoholics, report specifically 
what the candidate drinks, and how much. In reporting over-indulgence, 
draw the line at Anstie's limit of a daily allowance equivalent to one and a 
half ounces of absolute alcohol. Such allowance will be represented by 
three ounces of ardent spirits ; two wineglassfuls of sherry or strong wine ; 



i6 



The Life Insurance Examiner. 



a pint of claret, champagne or other light wine; three glasses of strong ale 
or porter, and four or five glasses of light ale or lager beer. In cases of ex- 
cess indicate it clearly. 

Blood Vessels. 

1. It is better to rate the pulse in the sitting posture and note its qual- 
ities, before further examination shall have excited the circulation. 

2. It often happens that, from exercise or the taking of food or stimu- 
lants just previous to the examination, the pulse becomes rapid, unsteady 
or even intermittent. The use of tobacco, strong coffee, tea, or the loss of 
a night's rest, will sometimes produce the same results. Always postpone 
such cases for subsequent examination, when, the cause being removed, the 
circulation may be found normal. In case frequency alone be the objection, 
by prolonging the interview and diverting the applicant's mind from the 
immediate subject in hand, the pulse will become fuller, and its frequency 
decrease. 

3. The exploration of the chest, for the detection of possible incipient 
disease of the heart, must be critical. Never be satisfied with the absence 
of abnormal sounds, but be positive of the presence of normal conditions. 

Respiratory Organs. 

1. The Examiner should exercise great care in his exploration of the 
thorax, remembering that he has probably only to detect the first symp- 
toms of thoracic disease. No examination can be satisfactory that is made 
through the clothing; the chest must in all cases be exposed, or at least 
only covered by the undergarment. 

2. The history of an attack of haemoptysis should not be looked upon 
as accidental, unless distinctly coincident with some injury inflicted, or some 
violent physical effort made at the time. It is often stated that the bleed- 
ing came from the gums or throat ; but the presumption is always against 
this origin, and it must be proved to the satisfaction of the Examiner before 
the risk is approved. 

3. The following table exhibits the proper average relation of height, 
weight and chest measurement : 



Height. 



5 feet, 1 inch. 
2 

5 



Weight- 
Pounds. 



120 

125 
130 

135 
140 

143 



Medium 

Chest. 



34.06 
35-13 
35-70 
36.26 
36.33 
37-50 



Height. 



5 feet, 7 inches, 

8 " . 

9 " ■ 
10 " 
n " 



.Weight- 
Pounds. 



145 
148 

155 
160 
165 
170 



Medium 
Chest. 



38.16 

38.53 
39-IO 
3966 
40.23 
40.80 



The Life Insurance Examiner. 17 

Note great excess of weight, or the opposite, especially whether it has 
been recently or rapidly acquired or lost. 

4. The chest measurement should be taken by adjusting the tape under 
the vest, between the second and third ribs anteriorly, and below the lower 
border of the scapulae posteriorly. The respiratory expansion should be 
at least from one and one-half to two inches. 

Alimentary Canal. 

1. Dyspepsia is sometimes a prelude to consumption or organic disease 
of the stomach, liver or kidneys. Its nature should in all cases be inquired 
into and reported upon. 

Urinary and Generative Organs. 

1. Symptoms of disease of the urinary organs (stricture, enlargement 
of the prostrate gland, stone, etc.) should be carefully investigated. 

Examination of Urine. 

1. The urine should always be voided in the presence of the Examiner 
or at the time of examination. It must be examined in all cases for albu- 
men and its specific gravity taken. Unless the specific gravity exceeds 
1.025, no test for sugar need be made. 

2. The urine of applicants for insurance of $30,000 and over must be 
examined microscopically as well as chemicallyo Other microscopical 
examination need not be made unless specially required by the home office. 

3. One great company directs as follows : 

" In the matter of testing the urine, so apply your tests as to detect 
the presence of even small amounts of albumen or of sugar. For such 
detection of albumen, the common heat and nitric acid test is efficient 
enough if applied in the following manner : First acidify with a drop or 
two of acetic acid, then fill a long test tube three-quarters full and, 
holding the same by the bottom, boil the upper portion, only, of its con- 
tents. Holding the tube now a few inches in front of a black background 
set before a window, compare the upper, boiled, stratum of fluid with the 
lower unboiled one, and any pathologically important amount of albumen 
will be shown by a distinct cloudiness of the upper stratum of urine, distin- 
guishable from the cloudiness of precipitated phosphates by its persistence 
after addition of a drop of nitric acid. As regards sugar, test for this con- 
stituent in all cases, regardless of specific gravities. In the beginning of 
diabetes, as in temporary glycosuria, the amount of glucose in the urine is 
commonly not enough to run the specific gravity out of bounds. Take by 
preference, furthermore, the urine secreted during active digestion, since in 
the beginnings of both albuminuria and glycosuria, the morbid constitu- 
ents nay be present during digestion while absent in the intervals." 



The Life Insurance Examiner. 



4. Another one gives the following excellent hints : 

u Be sure that the urine is that of the applicant, and examine it within 
twenty-four hours after it is voided. After noting the color, reaction and 
specific gravity, fill a clean test tube half full of the clear urine (previously fil- 
tered, if turbid), and holding it at an angle of forty-five degrees, allow nitric 
acid to trickle gently down its side and form a stratum, under the urine, at 
the bottom of the tube. If carefully done, the two fluids will not mingle. 
Should any hazy or whitish cloud be observed at the point where the 
urine and acid meet, apply heat, and if the cloud remains, albumen may 
be considered present.* 

" It is important to hold the test-tube in a proper light in order to dis- 
tinguish slight changes, where only a small amount of albumen is present. 
The best way is that advised by Dr. John Munn, viz. : Place some dark 
material over the lower part of the window, as a background, and draw the 
shade down to it. Now, holding the test-tube a little way from this back- 
ground, lift the shade forward enough to allow the rays of light to pass 
through the tube without shining into your eyes. In such a light and 
against the dark background, very slight opacity becomes visible. 

"To detect sugar: fill a clean test-tube to the depth of half an inch 
with Fehling's standard test solution and boil it. If it is pure and reliable, 
it will remain clear and of a dark blue color. While the clear solution is 
hot, add the urine a few drops at a time. Sugar will cause a deep yellow 
or orange colored precipitate before the amount of urine added equals the 
quantity of test solution employed. If there is no change, once more heat 
to boiling and stand it one side. When cool, if there is no change, sugar 
may be considered absent. Squibb's Fehling's Test Solution is reliable and 
can be obtained through any druggist. 

"When the specific gravity is above or below normal, or albumen or 
sugar are present in very small quantity, it will be well to collect the total 
secretion of twenty-four hours and examine a sample of this mixed urine. 

" The microscope should always be used when, in a case otherwise 
acceptable, there is a suspicion of disease requiring its aid for certainty, as 
where there is a history of calculus or cystitis." 

Medical Adviser. 

I. If information as to the present or past condition of the applicant 
be deemed necessary, it is desired that the Examiner procure it from the 
applicant's attending physician in a professional way, with the understand- 
ing that it will be treated as confidential by the company. Such informa- 
tion should be paid for by the Examiner as a regular office fee, and the 

* Note. — Urine containing resinous matters, as when a patient is taking turpentine, baLam 
copaiva, etc., will sometimes give a whitish-yellow cloudiness, similar to albumen, with nitfic and 
hydrochloric acids. The addition of alcohol will cause this to disappear at once. 



The Life Insurance Examiner. 19 



amount thus paid communicated in a private letter to the medical officers, 
who will cause it to be refunded. 

.Confidential. 

1. If, for any reason, the Examiner does not wish to present in the 
application certain specific facts disclosed by the examination, he must 
write a confidential letter to the Medical Department at the home office, 
detailing such information. In this way nothing of importance affecting 
the risk need be withheld from the home office. 

2. If so requested by the candidate, for the purpose of holding private 
his medical history, you are authorized to deliver to the agent your report 
sealed. 

3. In the event of your giving an adverse opinion upon a risk, or of 
your declining to examine a candidate because of foreknowledge of his in- 
eligibility, you are particularly requested to communicate the fact con- 
fidentially, stating name, residence and occupation of the objectionable 
candidate, date of your unfavorable action and reason for the same. 

Postponement or Declination. 

1. Whenever a Medical Examiner postpones or declines an applica- 
tion, he will please write a confidential letter to the Medical Department 
of the home office at once, giving the person's name, age, occupation and 
the reason for his action. 

2. If the applicant has suffered from any recent severe attack of illness, 
postpone his acceptance until a sufficient time shall have elapsed to show 
his restoration to firm health. 

Medical Examiner's Opinion. 

I. In forming your opinion of the life as an assurance risk, remember 
that the question is not merely the narrow one of whether or not the candi- 
date is, at the moment, healthy and sound, but is the broader subject of his 
chances of living — chances that may be affected as much by abode, occu- 
pation, habits of life and hereditary tendencies as by present condition of 
health. A wise judgment, therefore, requires the weighing of all the in- 
fluences now or prospectively affecting the life. 

Causes of Rejection. 

1. Considering them especially hazardous risks, one of the largest com- 
panies in the world will not insure any of the following classes of applicants : 
Gamblers, bar-keepers, hotel proprietors who tend their own bars, keepers 
of saloons where liquors are sold, billiard-room keepers, any retailer of alco- 
holic drinks or one personally engaged in their manufacture ; miners, day 
laborers, engineers and firemen either of stationary or moving engines ; men 
employed on any railroad train, or in switching or coupling cars ; men in 



20 The Life Insurance Examiner. 

blast furnaces, powder mills, fireworks or nitro-glycerine manufactories ; 
balloonists, ordinary seamen, men operating in steam mills or near circular 
saws ; divers or submarine workers of any kind. 

2. Another great company prints the following causes : 

" i. When both parents have died of consumption. 

" 2. When one parent (or two members, not parents) died of consump- 
tion, which parent the applicant more closely resembles, unless the family 
history is otherwise unexceptionable, the applicant himself possessed of 
healthy conformation, and has reached the age of at least thirty-five years. 

"3. If the applicant has raised blood, he is not at all insurable until 
after ten years, and then only in favorable cases, and for short endow- 
ments (except where it can be positively proved that the blood did not 
come from the lungs or air passages, in which case the home office will de- 
cide). 

"4. Where the party has been afflicted with paralysis, epilepsy, heredi- 
tary insanity, or symptoms denoting softening of the brain. 

" 5. If any of the preceding diseases have occurred in any two members 
of the applicant's family, he is to be regarded as insurable only upon the 
endowment plan, the term of insurance to expire prior to his reaching the 
age of fifty years. 

"6. Intermission or irregularity of the pulse or heart's action, abnormal 
sounds of this organ, habitual cough, difficulty of breathing, and asthma. 

"7. Diseases of the digestive organs materially affecting the health of 
applicant. 

11 8. Gout, fistula, irreducible hernia, frequent attacks of erysipelas or 
of colic, the existence of an open ulcer, disease of the spine, important 
tumors, and inflammatory rheumatism. 

"9. Diseases of the urinary organs." 

Female Applicants. 

1. If the applicant is a woman, ascertain whether the functions of the 
reproductive system are normal. 

2. Owing probably to the difficulty of ascertaining the peculiar physi- 
cal history of women in their applications, the experience of life insurance 
companies is that they have not generally proved to be profitable risks. 
Consequently, it is necessary to make their physical examination with the 
greatest care. 

3. In cases of pregnancy, postpone the application until a sufficient 
time has elapsed after delivery to indicate that the woman's constitution 
has not been affected. 

Rules Governing Proofs of Death. 
1. Specific information concerning the late habits of deceased, in re- 
gard to the use of alcoholics and narcotics, must be furnished ; and also the 
occupation must be fully stated. 



The Life Insurance Examiner. 21 

2. When death is caused by disease of the brain or from insanity, give 
the full particulars as to the cause and duration of the same. 

» 3. In case of suicide — a certified copy of the evidence and verdict of 
the coroner is required ; and in all cases of sudden death from unknown 
causes, the particulars and results of all investigations held must be sent to 
the company. 

4. Certificates of the disease causing death must be furnished by the 
attending and consulting physician. 

5. Every question must be distinctly and fully answered. The com- 
pany reserves the right to ask additional questions when necessary. 

Fees of Medical Examiners. 

1. The fee for examination, allowed by the company, in each case will 
be paid by the agent, and should be receipted for on the company's blank. 
But should the application be for less than $1000, the fee must be paid by 
the applicant. 

2. The additional fee for a microscopical examination of urine — where 
required by the foregoing rules — will be the same as that allowed for by 
the physical examination of the applicant. 

3. When examinations by two physicians are required (as in the case of 
a risk for $30,000 or over), but one microscopic examination shall be made, 
for which but one fee will be allowed as per rule. 

4. But one fee will be allowed for any number of examinations of the 
same applicant made within thirty days. 

5. Medical Examiners will be paid only the regular fee for examina- 
tions. All extra charges, as for transportation, or going unusual distances, 
must be paid by the agent. 

6. Each company declines to pay for the examination of any applicant 
whose occupation is described in the foregoing rules as especially hazard- 
ous. The Medical Examiner must look to the agent for his compensation 
where the applicant is so excluded. 

7. Bills for medical examination must be presented at the end of the 
current month. 



PART II. 

EXAMINATION OF THE APPLICANT. 



IDENTIFICATION. 

Signature. 

Name and Identification. — Although it is stated that the name 
identifies the applicant, when he is not personally known to the Medi- 
cal Examiner, the agent presenting him for insurance, or some other 
witness, should be held responsible for his identification. Carelessness in 
this respect has often subjected insurance companies to fraud, which might 
have been averted by care on the part of the Examiner. 

ENVIRONMENT. 

Occupation. 

We append at the close of this paragraph a table showing a classifica- 
tion of the relative influence of the various occupations on the duration of 
life in general, but it must be the task of the Examiner to determine, in each 
individual case, how far the applicant's particular employment is likely to 
prove prejudicial to longevity, in view of what is elicited by the insurance 
examination. One man may be so constituted as to bear with impunity a 
routine of life which would probably prove fatal to another. Statistics 
establish the general principles, to which individual exceptions can be taken, 
either in favor of or against the applicant. 

In some occupations danger of accidents must be considered ; in others, 
the general deleterious circumstances. A person below par in the scale of 
respiratory or circulatory power, may be safely insurable, provided his 
pecuniary means and occupation admit of the likelihood that he will take 
the requisite care of himself, thus neutralizing the risk. 

To the well-to-do merchant or professional man, an occasional attack of 
catarrh or bronchitis need not excite alarm, while the same ailment in a 
person whose occupation constantly furnished the exciting cause of such 
attacks, might suggest the possibility of eventual chronic disease. 

Professional Men. — Among this class, teachers show the greatest 
longevity ; but it is fair to admit that few occupations suffer from worse 
atmospheric conditions than those members of this class, who, as under-teach- 



The Life Insurance Examiner. 23 



ers in city schools, work up to the highest pitch of mental exertion, for six 
or eight hours a day, in poorly ventilated school-rooms, over-crowded with 
uncleanly children. Their standard of health is low, compared with the 
great majority of principals in high schools, and teachers in colleges and 
country schools, who reach the greatest age. 

Clergymen rank next, being subject to few diseases, except those 
resulting from a sedentary life. They suffer most from dyspepsia, and are 
not more liable to pulmonary complaints than the followers of other pur- 
suits. Lawyers are classed next; then professional lecturers, and then 
physicians. Physicians, as a class, owing to exposure and irregular habits, 
suffer a subtraction of one-fourth from the highest expectation of life ; 
but in individual cases this does not apply. 

City and Country. — In regard to physicians, it may. be said that the 
country doctor, on account of necessary hardships, is a less favorable risk 
than his city brother. Concerning the ether professions, the general standi 
ard of health is about the same in the city as it is in the country, not- 
withstanding the fact that the latter undoubtedly offers greater natural 
advantages for the enjoyment of health. What the city lacks in certain 
respects is made up by the more general observance of sanitary require- 
ments in the matter of dwellings, sewage, dirt, dress, exercise, personal 
cleanliness, the timely heeding of professional advice, etc. 

ARTISTS. — Picture painters, who spend much time out of doors, and 
sculptors, who model but do not chisel the marble themselves, are classed 
next to professional men, and prove better risks than those of the same 
craft who paint and fashion the stone in studios. Photographers rank 
second class. 

Artisans and Mechanics. — Painters, using lead, turpentine and oils, 
require careful scrutiny before they can safely be admitted. For their case, 
outside work in the fresh air is preferable to indoor work, and the constitu- 
tion and physical status must be sound. 

Workers in phosphorus and quicksilver present the same objections. 
Stone-cutters, millers^ and those engaged in similar occupations, which neces- 
sitate constant breathing of air laden with irritating particles, are question- 
able risks, unless the applicant is exceptionally strong and careful, and his place 
of business is provided with improved methods of ventilation. Glass-blowers 
and type-setters are indifferent risks, both on account of bad air and bad habits. 
Blacksmiths, furnace-men, carpenters, coopers and cabinet-makers are among 
those engaged in the more healthy pursuits. Shoemakers and harness-makers, 
being more sedentary in their habits, rank second class, as do tailors. Butch- 
ers and marketmen, aside from their liability to accidents, are first class. Ma- 
chinists, plumb ers, tinsmiths, tallow cha?idlers and barbers, etc., are average risks. 
Engravers, jewelers and the like, suffer from lack of exercise, but are in 
other respects unobjectionable. Brewers, confectioners, dyers, hatters, bakers, 
bath attendants, and others who are subject to sudden changes of temper- 



24 



The Life Insurance Examiner. 



ature, from hot to cold, and wet to dry, are not desirable as a rule. Chem- 
ists, assayers, gilders, tobacconists, etc., come under the same head. Day 
laborers, unless exposed to accidents, are good risks. Farm laborers in 
healthy localities are among the best risks. 

ACCIDENTS — Among sailors^ thirty-five per cent of the deaths are due 
to accident, but they enjoy greater immunity from sickness than the popu- 
lation at large. For miners, the ratio is twenty-five per cent ; engineers and 
assistants, fifteen per cent ; painters, plumbers and glaziers, ten per cent. 

Army AND Navy. — The recruit, after he has passed the rigid examin- 
ation and is admitted to the service, should be considered above the aver- 
age risk. 

The diseases to which he is most exposed in the army or navy, are 
malarial and typhoid fevers, rubeola, diarrhoea, dysentery, rheumatism, 
scurvy, pneumonia, catarrh, heart disease, Bright's disease and venereal 
affections. A careful examination is requisite, because these applicants 
undergo severe hardships from the exposures and exigencies of the service, 
which are liable to induce organic diseases. 

Previous Employment. — While the present occupation may be salu- 
tary, the previous employment may have left traces of serious disease, 
which should be recognized. 

The Best Lives are those exposed sufficiently to the fresh air, and 
supplied with moderate physical exercise, combined with variation enough 
to maintain the fund of interest in living. Under proper protection, the 
change of seasons in the temperate zone is conducive to health and long life. 

Classification of Risks According to Occupation. 



Brakemen on freight trains. 
Buzz sawyer. 



CLASS I. 



Circular sawyer. 
Powder maker. 



Seamen. 



Bridge builder. 

Boatman. 

Barber on steamboat. 

Brakemen on mail trains. 

Cartridge maker. 

Clerk on river steamboat. 

Captain of lake or sea vessel. 

Car coupler. 

Conductor on freight trains. 

Cooper. 

Dock laborer. 

Engineer on river steamer. 

Furrier. 

Fireworks, maker of. 

Fireman, locomotive. 



CLASS II. 

Grinder of edged tools. 

Horseshoer. 

Laborer, wharf, warehouse, 

grain elevator. 
Lighterman. 
Lumberman. 
Master or mate of vessel. 
Match maker. 
Mail agent, traveling. 
Mate of river steamer. 
Miner, underground. 
Nightman. 
Pilot. 
Quarrier. 
Quarryman. 



Raftsman. 

Railroad engineer. 

Race horseman. 

Sailor. 

Steward of steamboat. 

Switchman. 

Stevedore. 

Slater. 

Steel polisher. 

Telegraph builder. 

Timber cutter. 

Train starter. 

Wood carver and turner. 

Yard master. 



The Life Insurance Examiner. 



25 



CLASS III. 



Agricultural implement maker. 

Barkeeper. 

Blacksmith (working). 

Blast furnace (working in). 

Block, oar and mast maker. 

Boiler maker. 

Bolt maker. 

Brass founder (working). 

Bricklayer. 

Broker in cattle and horses. 

Baggage master on trains. 

Baggage master at station. 

Canal boatman. 

Captain on river steamer. 

Car driver. 

Carman (drayman). 

Carpenter and joiner. 

Caulker (ship). 

Coachman. 

Cork cutter. 

Cooper. 

Coal heaver. 

Carpenter (railroad). 

Chief engineer, 

Car repairer. 

Car cleaner. 

Conductor on passenger trains. 

Distiller. 

Driver of express wagon. 



Drover. 

Detective (railroad). 
Express agent (not on trains). 
Express agent on trains. 
Engineer on stationary engine. 
Express messenger on trains. 
Foundry (employee in). 
Fireman (engine, hose, hook 

and ladder). 
Freight agent (station). 
Freight laborer. 
Hod carrier. 
Horse breaker. 
Hostler. 

Inspector of wood and timber. 
Knife and instrument maker. 
Lead pipe and tube maker. 
Lighthouse or lightship keeper. 
Lightning rods (one who puts 

up). 
Livery stable keeper. 
Lumberman, manufacturer. 
Laborer, common. 
Locomotive superintendent. 
Limestone quarrier or burner. 
Master mechanic* 
Mason. 
Machinist. 
Metal turner. 



Miner (surface). 
Naval architect. 
Operative in saw and planing 

mill. 
Painter. 

Prison office keeper. 
Puddler. 
Rolling mills. 
Saw mill (employee). 
Shooting gallery keeper. 
Scythe and sickle maker. 
Ship carpenter. 
Shipsmith. 
Slate quarrier. 
Stable keeper. 
Stage driver. 

Sugar refinery (workman in). 
Station man. 
Signal man. 
Ship inspector. 
Stone cutter and dresser. 
Track laborer. 
Track superintendent 
Track foreman. 
Track inspector. 
Teamster. 

Turpentine manufacturer. 
Watchman. 
Wood chopper. 



CLASS IV. 



Actor, actress. 

Ale or beer manufacturer. 

Apothecary, druggist. 

Architect. 

Armorer. 

Artificial limb maker. 

Actuary. 

Artist, painter. 

Attorney, lawyer. 

Auditor. 

Army or navy officer (not in 

service). 
Author, writer. 
Bookseller. 

Broker in mdse., stocks or gold. 
Bank officer or clerk. 
Bookkeeper, accountant. 
Baker. 
Barber. 
Basket-maker. 



Bell-hanger. 

Boat builder 

Bookbinder. 

Boot and shoe maker. 

Box and trunk maker. 

Brass polisher, finisher. 

Brewer. 

Brickmaker. 

Builder, not laborer. 

Cabinet maker. 

Cap or carpet-bag maker. 

Carpet weaver. 

Chair maker. 

Chemist and druggist. 

Chiropodist. 

Civil engineer. 

Clock maker. 

Coach maker. 

Coffee-house keeper. 

Commercial agent. 



Clergyman, minister. 

Clerk (generally). 

Clothier. 

Commission merchant. 

Captain of lake or sea steamer. 

Chemist, manufacturing. 

Coal miner (underground). 

Confectioner. 

Cook (professional). 

Coppersmith. 

Copperplate printer. 

Cornice moulder. 

Cotton dyer. 

Cotton packer and presser. 

Cotton printer. 

Cow-keeper, milk seller. 

Currier. 

Custom-house officer. 

Cutler. 

Draughtsman. 



26 



The Life Insurance Examiner. 



Dressmaker. 

Dentist. 

Die engraver, mould maker. 

Drug Grinder. 

Eating-house keeper. 

Embosser. 

Embroiderer, 

Engraver 

Editor, reporter. 

Engineer, mining 

Fisherman. 

Farmer, owner. 

Farm laborer. 

File maker. 

Fish curer. 

Fish and oyster dealer. 

Furrier. 

Gardener. 

Gas titter. 

Gas works, service. 

Gauger. 

General trader (traveling). 

Glazier. 

Glover. 

Gold beater. 

Glass blower. 

Gold or silver refiner and 
worker. 

Grocer (general). 

Grain measurer. 

General trader, storekeeper. 

Grave digger, sexton. 

Gunsmith. 

Harness maker, saddler. 

Hat and cap maker. 

Hollow ware maker. 

Hoop maker. 

Hoop skirt maker. 

Hotel or tavern keeper (coun- 
try). 

House decorator. 

Huckster. 

Hotel keeper, proprietor. 

Insurance officer and clerks 
(not traveling). 

Ivory cutter and worker. 

India rubber manufactory, em- 
ployee in. 

Ink maker. 

Instrument case maker. 

Japanner. 

Jeweler, worker. 

Lithographer (not working). 



CLASS IV .—Continued. 

Leather dyer. 

Locksmith. 

Looking glass maker. 

Last maker. 

Machinist, not in employ of 
railroad. 

Marble cutter. 

Marble mason. 

Marketman. 

Medical student. 

Metal refiner. 

Miller, grain and flour. 

Morocco dresser. 

Millwright. 

Manufacturer (not working). 

Milliner. 

Musician 

Moulder. 

Naval officer, in service. 

Nail maker 

Nurseryman, working. 

Oil dealer, petroleum. 

Operative in cotton or woolen 
mills. 

Organ builder. 

Oyster dealer. 

Phonographer. 

Photographer. 

Physician. 

Postmaster. 

P. O. Clerk (not traveling). 

Packer of hay, cotton, pork, 
beef. 

Packing case maker (not using 
circular saw). 

Painter, house, ornamental. 

Paper hanger. 

Paper box maker. 

Pastry cook. 

Pawnbroker. 

Pencil maker. 

Picture frame maker. 

Percussion cap maker. 

Plasterer. 

Plater. 

Plumber. 

Porter. 

Potter. 

Pressman. 

Printer, compositor. 

Pump maker. 

President or secretary of cor- 
poration. 



Publisher. 

Purser, steamship. 

Policeman. 

Railroad employees. 

Rectifier. 

Rope maker. 

Surgeon. 

Ship rigger. 

Soap boiler. 

Sail maker. 

Saloon keeper. 

Sausage maker. 

Segar maker. 

Scourer, dyer. 

Ship broker, agent. 

Ship builder, contractor. 

Steward on vessel or steamer. 

Smelter. 

Soda water manufacturer. 

Shovel maker. 

Silversmith. 

Spindle maker. 

Spring maker. 

Steel pen maker. 

Stereotyper. 

Surgical instrument maker. 

Surveyor. 

Tanner. 

Tinman, tinker. 

Traveling agent. 

Type founder. 

Tailor. 

Teacher. 

Telegraph operator. 

Tool maker. 

Turner, wood or ivory. 

Umbrella maker. 

Upholsterer. 

Varnish maker. 

Vitriol manufacturer. 

Watchmaker. 

Weighing machine, scale maker. 

Wharfinger. 

Wheelright. 

Whipmaker. 

Whitesmith. 

Wigmaker. 

Wire maker. 

Wood dealer. 

Watchman. 

Weaver. 

Weigher. 



The Life Insurance Examiner. 



Climate. 

The influence of a change of climate in increasing or decreasing the life 
expectation should always be regarded by the Insurance Examiner; and 
the past or future effects of this element in the risk should be carefully 
ascertained and calculated. This subject is deserving of more attention 
from insurance authorities. 

The most healthful climate lies between the thirtieth and fiftieth par- 
allels of latitude, and the best insurance risks are found among the inhabit- 
ants of this zone. 

The temperature of Europe, within equal parallels, is higher than that 
of America, and the diseases of lower climates prevail in higher latitudes 
on the Continent. 

Acclimation is the term used to express a certain change of constitu- 
tion, which inures the animal system against the liability to contract acute 
diseases or endemics prevalent in certain localities. 

Excessive meteorological changes, as indicated by the thermometer, 
barometer and hygrometer, subject those inhabiting such places to various 
diseases, and thus tend to impair risks. 

Moist and warm climates predispose to malarious affections ; cold, 
variable and moist, to the consumptive cachexia ; dry and variable, to rheu- 
matic and inflammatory diseases. 

A change from North to South is apt to derange the functions of the 
skin, liver, spleen and intestines by necessitating increased activity of those 
organs, which may lead to organic or malarious diseases. If the action of 
the skin becomes sluggish, the acute or chronic diarrhoea of hot climates 
may ensue. In other cases we observe symptoms of ague, jaundice and 
dropsy — it may be exhibited in the same person — such as the dark yellow 
complexion, distorted features, livid eyes and lips and a bloated abdomen. 

Yellow fever is an epidemic disease, usually confined to cities and 
towns, and acclimation against the so-called malarious diseases does not 
afford immunity from it. One attack of yellow fever is supposed to pro- 
tect against further infection ; nevertheless the constitution is frequently 
impaired by its ravages, and organic disease may date from an attack of this 
fever ; the Examiner must therefore be forewarned. Dr. Nott refers 
pointedly to this subject: u The citizen of the Southern town is fully accli- 
mated to its atmosphere, but cannot spend a single night in the country 
without serious risk of life ; nor can the squalid, liver-stricken countryman 
come into the city during an epidemic of yellow fever without danger of 
dying with black vomit." 

The change from South to North may prove equally baneful. A 
healthy Southerner is liable to become the prey of tuberculous, kidney or 
inflammatory disease, unless he obeys the general laws of acclimation. 



26 



The Life Insurance Examiner. 



Dressmaker. 

Dentist. 

Die engraver, mould maker. 

Drug Grinder. 

Eating-house keeper. 

Embosser. 

Embroiderer. 

Engraver 

Editor, reporter. 

Engineer, mining 

Fisherman. 

Farmer, owner. 

Farm laborer. 

File maker. 

Fish curer. 

Fish and oyster dealer. 

Furrier. 

Gardener. 

Gas fitter. 

Gas works, service. 

Gauger. 

General trader (traveling). 

Glazier. 

Glover. 

Gold beater. 

Glass blower. 

Gold or silver refiner and 
worker. 

Grocer (general). 

Grain measurer. 

General trader, storekeeper. 

Grave digger, sexton. 

Gunsmith. 

Harness maker, saddler. 

Hat and cap maker. 

Hollow ware maker. 

Hoop maker. 

Hoop skirt maker. 

Hotel or tavern keeper (coun- 
try). 

House decorator. 

Huckster. 

Hotel keeper, proprietor. 

Insurance officer and clerks 
(not traveling). 

Ivory cutter and worker. 

India rubber manufactory, em- 
ployee in. 

Ink maker. 

Instrument case maker. 

Japanner. 

Jeweler, worker. 

Lithographer (not working). 



CLASS IN .—Continued. 

Leather dyer. 

Locksmith. 

Looking glass maker. 

Last maker. 

Machinist, not in employ of 
railroad. 

Marble cutter. 

Marble mason. 

Marketman. 

Medical student. 

Metal refiner. 

Miller, grain and flour. 

Morocco dresser. 

Millwright. 

Manufacturer (not working). 

Milliner. 

Musician. 

Moulder. 

Naval officer, in service. 

Nail maker 

Nurseryman, working. 

Oil dealer, petroleum. • 

Operative in cotton or woolen 
mills. 

Organ builder. 

Oyster dealer. 

Phonographer. 

Photographer. 

Physician. 

Postmaster. 

P. O. Clerk (not traveling). 

Packer of hay, cotton, pork, 
beef. 

Packing case maker (not using 
circular saw). 

Painter, house, ornamental. 

Paper hanger. 

Paper box maker. 

Pastry cook. 

Pawnbroker. 

Pencil maker. 

Picture frame maker. 

Percussion cap maker. 

Plasterer. 

Plater. 

Plumber. 

Porter. 

Potter. 

Pressman. 

Printer, compositor. 

Pump maker. 

President or secretary of cor- 
poration. 



Publisher. 

Purser, steamship. 

Policeman. 

Railroad employees. 

Rectifier. 

Rope maker. 

Surgeon. 

Ship rigger. 

Soap boiler. 

Sail maker. 

Saloon keeper. 

Sausage maker. 

Segar maker. 

Scourer, dyer. 

Ship broker, agent. 

Ship builder, contractor. 

Steward on vessel or steamer. 

Smelter. 

Soda water manufacturer. 

Shovel maker. 

Silversmith. 

Spindle maker. 

Spring maker. 

Steel pen maker. 

Stereotyper. 

Surgical instrument maker. 

Surveyor. 

Tanner. 

Tinman, tinker. 

Traveling agent. 

Type founder. 

Tailor. 

Teacher. 

Telegraph operator. 

Tool maker. 

Turner, wood or ivory. 

Umbrella maker. 

Upholsterer. 

Varnish maker. 

Vitriol manufacturer. 

Watchmaker. 

Weighing machine, scale maker. 

Wharfinger. 

Wheelright. 

Whipmaker. 

Whitesmith. 

Wigmaker. 

Wire maker. 

Wood dealer. 

Watchman. 

Weaver. 

Weigher. 



The Life Insurance Examiner. 27 



Climate. 

The influence of a change of climate in increasing or decreasing the life 
expectation should always be regarded by the Insurance Examiner; and 
the past or future effects of this element in the risk should be carefully 
ascertained and calculated. This subject is deserving of more attention 
from insurance authorities. 

The most healthful climate lies between the thirtieth and fiftieth par- 
allels of latitude, and the best insurance risks are found among the inhabit- 
ants of this zone. 

The temperature of Europe, within equal parallels, is higher than that 
of America, and the diseases of lower climates prevail in higher latitudes 
on the Continent. 

Acclimation is the term used to express a certain change of constitu- 
tion, which inures the animal system against the liability to contract acute 
diseases or endemics prevalent in certain localities. 

Excessive meteorological changes, as indicated by the thermometer, 
barometer and hygrometer, subject those inhabiting such places to various 
diseases, and thus tend to impair risks. 

Moist and warm climates predispose to malarious affections ; cold, 
variable and moist, to the consumptive cachexia ; dry and variable, to rheu- 
matic and inflammatory diseases. 

A change from North to South is apt to derange the functions of the 
skin, liver, spleen and intestines by necessitating increased activity of those 
organs, which may lead to organic or malarious diseases. If the action of 
the skin becomes sluggish, the acute or chronic diarrhoea of hot climates 
may ensue. In other cases we observe symptoms of ague, jaundice and 
dropsy — it may be exhibited in the same person — such as the dark yellow 
complexion, distorted features, livid eyes and lips and a bloated abdomen. 

Yellow fever is an epidemic disease, usually confined to cities and 
towns, and acclimation against the so-called malarious diseases does not 
afford immunity from it. One attack of yellow fever is supposed to pro- 
tect against further infection ; nevertheless the constitution is frequently 
impaired by its ravages, and organic disease may date from an attack of this 
fever ; the Examiner must therefore be forewarned. Dr. Nott refers 
pointedly to this subject: " The citizen of the Southern town is fully accli- 
mated to its atmosphere, but cannot spend a single night in the country 
without serious risk of life ; nor can the squalid, liver-stricken countryman 
come into the city during an epidemic of yellow fever without danger of 
dying with black vomit." 

The change from South to North may prove equally baneful. A 
healthy Southerner is liable to become the prey of tuberculous, kidney or 
inflammatory disease, unless he obeys the general laws of acclimation. 



28 The Life Insurance Examiner. 



Acclimation to temperate climates, where no extreme changes occur, 
is an easier matter, but sudden variations of weather conduce to catarrhal 
affections and rheumatism. 

Prevention of such climatic diseases as may chance to prevail in any 
locality, depends most upon a certain soundness of constitution inherent 
in some individuals and families, but, also, upon the scrupulous adaptation 
of one's life to the changed environment. As Dr. W. A. Hammond ob- 
serves: " For an Englishman or an American to attempt a residence in 
latitude eighty degrees without changing his food, clothing and habits to 
conform with the change of climate, would lead to certain death. But if 
he studies the surrounding conditions and profits by the experiences of the 
natives, he soon becomes acclimated and lives in health and comfort." And 
the same is true of a change from cold to hot countries. The best prophy- 
laxis against all fevers is an alert desire to keep well. 

Permission to make these extreme changes should, therefore, depend 
upon the actual history and experience of the applicant, as referred by the 
Examiner to the executive officers, who may wisely grant him permission 
to make his permanent residence in a far Northern or Southern climate, if 
the facts demonstrate that he has heretofore maintained sound health under 
like conditions, or is a native of the climate to which he would return. 

Reference should here be made to the proclivities whi^li the different 
physical temperaments have for certain diseases, to be found in the section 
on Physique and Temperament. 

Residence in city, town and country, as regards expectation of life, 
stands unquestionably in favor of the country, when we consider the total 
mortality, which is about twenty-five per cent greater in cities than towns. 
But among thrifty people, who live in cities and are able to insure, the 
superior sanitary and hygienic provisions against endemic and epidemic dis- 
eases just about counterbalance the advantages of country air and quietude. 

The general influence of climate has had its specific effect in modifying 
the different races of mankind. The study of philology demonstrates the 
fact that most of the nations of modern Europe have descended from the 
same Aryan parents as have the inhabitants of the Indian peninsula. 
Climate, acting through the geological eras, has so modified them as appar- 
ently to produce different races. At the present time the Aryan races of 
Europe cannot rear their children in the climate of India, where their 
Hindoo relatives thrive and propagate their species, and ever since history 
began the European races have tried in vain to populate the tropical 
regions — but it has been shown to be impracticable — and this fact should 
receive due consideration from a life insurance standpoint. 



The Life Insurance Examiner. 29 



PHYSIQUE. 

Age. 

The question of age has an important general bearing upon the subject 
of life insurance, and the applicant should be carefully questioned and scru- 
tinized on this point. It is a gauge of the vital force of the individual, and 
determines the amount of premium required by the company. As a gen- 
eral rule, persons having passed the climacteric and become confirmed in 
regular habits, are even more eligible, under the higher rates of insurance, 
than those much younger, who are more liable to casualties and sudden 
diseases. 

Diseases. — Different ages are liable to particular diseases. The tend- 
ency to hereditary diseases, at a certain age, may have been outgrown, or 
not yet reached. According to age, the tendency to disease and death is 
very great. One-tenth of all children born, die during the first month. In 
cities and towns nearly one-half die before the fifth year. Between the age 
of puberty and maturity, placed at twenty-five years, the respiratory and 
strumous diseases are especially fatal. None should be insured before 
puberty except at special rates. 

Between puberty and maturity, the Examiner should lay extra stress 
upon the examination of the respiratory and glandular systems. Fevers, of 
the typhoid or continued varieties, are also destructive during this period. 
The exanthematous diseases exhaust the constitution, and favor the germi- 
nation of phthisis and other strumous disorders. If rheumatism attacks a 
person in this decade of life, in which the sanguineous system is so active, 
it is apt to induce valvular disease of the heart, with its complications and 
sequelae. 

From the twenty-fifth to the fortieth year, the age of full maturity, the 
best risks are taken. In these years the applicant reaches his best physical 
development. Hereditary predispositions are in abeyance, and evil influ- 
ences from without are more easily resisted. 

In this period the personal habits and external influences require more 
careful scrutiny. 

At the fortieth year decline begins, hereditary tendencies resume their 
influence and acute affections meet with less resistance, although they are 
not so prevalent as in the first two decades of life. The proclivity 
henceforth is rather toward congestions than active inflammations, and 
toward fatty and other degenerations, toward cardiac obstructions from 
morbid deposits, toward dropsies, paralyses, apoplexies, urinary diseases, etc. 

The following table is taken from the reports of the Mutual Life 
Insurance Company, and shows the percentage of deaths, among over 5000 
insured persons, from different diseases. 



30 



The Life Insurance Examiner. 



Percentage of Deaths, Age and Diseases Among 5000 
Insured Persons. 



DISEASES. 



Typhoid fever 

Other zymotic diseases 

Cancer 

Other constitutional diseases., 

Consumption 

Apoplexy 

Other nervous diseases 

Heart diseases 

Pneumonia 

Respiratory diseases 

Digestive diseases 

Urinary diseases 

Accidents and suicides 

Old age and unclassified 



Years. 



30 to 39 40 to 49 50 to 59 60 to 69 70 10 79 



13 93 
11. 6S 

■41 
2.05 

34.22 
1.64 
5-94 
1.84 
4.10 
4.71 
6-35 
1.64 

10.25 
1.23 



7-23 

13-86 

. 9 3 

i-75 

25.06 

2.52 

8.96 

3-97 
6.51 
5.67 
S.75 
2.31 
10.50 
2. 17 



6.36 
12.52 

1. 13 

2.98 

17-43 
6.96 

10 40 
5.10 
7-6q 
4-57 
9-94 
3-9i 
8.42 
2.5S 




The foregoing table shows only the proportion of diseases as a cause 
of death among about 5000 of the insured, and not the actual frequency at 
the age given for the whole population. The latest statistics demonstrate 
that deaths from consumption are of nearly equal percentage at all ages. 
Pneumonia is also equally prevalent at all ages, but since it is more fre- 
quently fatal in advancing age, the percentage of mortality is greater then. 
Casualties are more frequent among the young, because they are more 
careless and more exposed to accidents in traveling and business. A 
tendency to apoplexy and kidney diseases seems to develop between the 
ages of thirty- five and forty ; to diseases of the heart, about forty-five years. 

Apparent Age. — There is often a marked discrepancy between the 
age given and the apparent age of the candidate for insurance. It is 
desirable that he should appear the age he assigns to himself; and while it 
is still more favorable if he seems younger than he really is, it is decidedly 
the reverse if he appears older. Some are relatively older at thirty than 
others at fifty. Owing to the increased respect for sanitary laws, and, per- 
haps, still more to the ministrations of the dentist and the barber and to the 
arts of the toilet, it is becoming more and more difficult to infer the actual 
age from the general appearance. The Examiner must be on the lookout 
for those little deceptions practiced by society in the use of hair dyes, prep- 
arations for the complexion, etc. 



The Life Insurance Examiner. 



PREMATURE Old Age.— Premature old age may be the result of 
hereditary or congenital imperfections, of previous illness, irregular or 
dissipated "habits, overwork or exposure. 

The decline of life begins at periods varying with the state of the 
inherited, or acquired vigor of the individual. Any exhausting influences, 
in the absence of actual disease, will occasion premature senility and impair 
the prospect of life, and such persons should rarely be insured. 

As the ratios of insurance are calculated from the known prospect of 
life at each age, the Examiner, when asked, should feel no reluctance in 
advising persons of advanced age to secure insurance, provided their aver- 
age health is good and the physique of the applicant is excellent. 

Expectation of Life. — The fallacy concerning the insecurity of old 
lives was long ago exploded. If they have passed safely through the 
dangers that beset early life, have learned how to care for health, and .are 
in good physical condition, they are entitled to insurance. 



Table of Expectation of Life. 

Or average duration of life, at any age, for each individual. From the Carlisle Table 

of Mortality. 



Age. 



O: 
I 

2, 
3 

4 

5 

6 

7. 

3 

9 

10 
11 
12 
13 
14 
15 
i& 

17 



Expecta- 


tion. 


33. 


72 


44. 


68 


47 


55 


49 


82 


50 


76 


5i 


25 


5i 


17 


50 


80 


50.24 


49 


57 


48 


82 


48 


04 


47 


27 


46 


5i 


45 
45 
44 


75 


.27 


43 


•57 



Age. 



18. 
19. 

20. 
21. 
22. 
23- 

24- 
25- 

26. 

27. 

28. 

29- 

30. 

3i- 
32. 
33- 
34- 



Expecta- 
tion. 



Age. 



35- 
36. 
37. 
38. 

39 
40. 
41. 

42. 
43 
44 
45 
46 

47 

48 

49 
50 
5i 



Expecta- 


tion. 


31 


OO 


30 


32 


29 


64 


28 


90 


28 


28 


27 


6l 


26 


97 


26 


34 


25 


7i 


25 


09 


24 


46 


23 


82 


23 


17 


22 


50 


21 


.81 


21 


11 


20 


•39 



Age. 



Expecta- 
tion. 



53 
54 
55 
56 
57 
58 

59 
60 
61 

62 
63 

64 
65 

66 

67 

6S 



19.68 
18.97 
18.28 
17.58 
16.89 
16.21 

15-55 
14.92 

14-34 
13-82 

1331 
12.81 
12.30 
11.79 
11.27 
IO-75 



Other tables vary this expectation from one to two per cent, 



The Life Insurance Examiner. 



English and American Mortality Rates. 



A :- 1 . 



American 
Table. 

Number 
Living. 



Combined 

Experience. 

Number 

Li ring. 



American 
Table. 
Number 
Dving. 



Com- 
'; re; z.::- 
perience. 
Number 

Dying. 



American 
Table. 

Expectation 
of Life. 



i English 
Lite 
Table 
No. 3 
Expecta- (Males), 
tionof Life. Expecta- 
| tion of 
I Lite. 



II. 

: : 

13. 

14. 

15 

16. 

17. 

:: 

19. 

20. 

21. 

22. 

23. 
-- 
25. 
26. 

-" ■ 

2fl 

30. 
31. 

32. 

34- 
- : . : 
36. 
37 

39- 

40. 

41. 

42. 

43- 

44- 

-I 

46. 

47 

48- 

49 

50 

5i 

52 

- : ; 

54- 

55- 

56. 

57- 

5« 

59- 

60. 

61.. 

62. 

63.. 

64.. 



: : : 
98.505 

97,762 
97,022 
96.2S5 

: :: : 

93.362 
92,637 

91.192 
90 471 

S9.032 

- :"■ 

S6,i6o 
»5 --- 

- "-- 
S4 000 

•;- :-- 

- 
81.822 

Si 090 
" 353 

79.6n 

-• • : 

-- 341 

76.567 

-; 782 

74 •' 
74 173 
73 345 

"- 495 

-: :;- 

70.731 

- - 

- : ; _ : 

- 841 
797 

65,706 

- : 3 
. : 3 - 

62,104 
60.779 
59385 
57.917 
56.371 
54.743 
53.030 
= 1.2^0 



100,000 

1.324 

97.307 
96,636 

95.965 
95.293 
94.62O 

93.263 

91.905 
91.219 

- -: 

:- : : 

■ _ : 

-: : : 

" - : " 

77 

77 012 

" 173 

" : - 
72 582 

7r,6oi 

" : i • 
69 517 
I _ 3 

" 253 

66,046 

:'_ 785 
63469 
62,094 

59-161 - 

57 600 

5 5-973 
54 --': 
52,505 
50,661 

-'■ 744 



"- 
74 
743 

740 
737 
73S 
732 

729 
-:- 
725 

"-"■ 
722 

--- 

-- 

- 

719 
72 

"- 

726 

~- 
732 

737 
74* 

749 
756 

774 

? " 

MS 

S96 

-' 

962 

I 001 

I.044 

1,091 

I 143 

I I '■ 
1,260 
I 325 
1-394 

: _ a 
1.546 

1,623 

1,713 

i,Soo 
1.880 



676 
674 

72 
671 
671 
671 
672 
673 

75 

"- 

- 
6S3 
656 
690 
694 
- 
703 

""- 
72 

"-- 

74* 

-- 
-■ 

77 
785 

795 

- -- 

909 

-- 

1,021 
: 

i.iof 
1,156 

1.207 
1 261 
1. 316 
: 375 

1.497 
1 ;6i 
1.627 
1.693 
: 77c 
: -__ 
: -.:- 
1,990 



-• 72 

_- • 

46.16 
45 5 

44 19 

42 - 
42 - 

40.17 

36.73 
3603 

|i 1 

30.35 
29.62 

:• 

27-45 
: 72 

-" 

25-27 
-- 54 

- \ - 
23.08 

22 3 

- I I 
20 gt 
20.20 

: - 
-- - 
iS 09 

17.40 

16.72 
16 05 

15-39 
14.74 
14.09 
13-47 

12.86 

12.26 

11. 65 



47-63 
47-OI 

45 64 
44-96 

44- 27 

42.19 

? 

4009 

34-43 
72 

30.15 

- 44 

- 72 

-• 

-" - 
26.^6 

24 4 

22 " 
22.27 

2I.56 

19.50 

:- :_ 

18.16 

17.50 

16.56 
16.22 

: i 
14 97 

-- 57 

:: .. 

12.61 
12.05 
11. 51 



47.05 
46.31 

43-97 
43.18 

42.40 
41.64 
40.90 

37-46 
56.79 

- 
55-44 

n 

3410 

3276 
32.09 

3 74 

30.07 
29.40 

-• 

26 72 
26.06 
25-39 
-- 73 
2407 
25-41 
22.76 
22.11 
21.46 

20 17 

1S.90 
[8.2I 

17.67 
17.06 
16.45 

15-56 

14.63 
14.10 

12 96 
12 41 
II.87 

11.34 



The Life Insurance Examiner. 



33 



English and American Mortality Rates. — Continued. 



Age. 



65 
66 

07 
68 
69 

70 
7i 
72 
73 
74 
75 
76 
77 
78 
70 
80 
8r 
82 
83 
84 
85 
36 

87 
88 

SQ 
90 

9i 
92 

93 
94 

05 



American 
Table. 
Number 
Living. 



49-341 
47o6l 
45,291 
43.133 
40,890 

3S,569 

36,178 

33,730 

3L243 

28,738 

26,237 

23,76l 

21,330 

18.961 

16,670 

14,474 

12,383 

10,419 

8,603 

' 6,955 

5,485 

4.193 

3,079 

2,146 

1,402 

847 

462 

216 

79 
21 

3 



Combined 

Experience. 

Number 

Living. 



46,754 
44.693 
42,565 
40,374 
38,128 

35.837 
33,5io 
3LI59 
28,797 
26.439 
24,100 
21,797 
19.548 
17.369 
15,277 
13,290 
11,424 

9694 
8,112 
6,685 
5 417 
4.306 
3,348 
2,537 
1,864 

1,319 
892 
57o 
339 
184 





Com- 


American 
Table. 


bined Ex- 


Number 
Dying. 


perience. 
Number 
Dying. 


1,980 


2,061 


2,070 


2.I2S 


2,158 


2,191 


2,243 


2,246 


2 321 


2,291 


2.39i k 


2,327 


2,448 


2,351 


2,487 


2,362 


2.505 


2,358 


2,501 


2,339 


2 476 


2,303 


2.431 


2,249 


2,369 


2,179 


2,291 


2,092 


2.196 


1,987 


2,091 


1,866 


1.964 


1,730 


1,816 


1,582 


1,648 


1.427 


1,470 


1,268 


1,292 


1, in 


1,114 


958 


933 


811 


744 


673 


555 


545 


385 


427 


246 


322 


137 


231 


58 


155 


18 


95 


3 


52 



American 

Table. 

Expectation 

of Life. 



11. 10 

10.54 
10.00 
9.48 
8.98 
8.48 
8.00 



48 

10 

74 

38 

04 

7i 

39 

3-o8 

2.77 

2.47 

2.19 

1-93 
1.69 
1.42 

1. 19 
.98 
.80 
.64 
.50 



Combined 
Experience. 

Expecta- 
tion of Life. 



10.97 

10.46 

9.96 

9-47 
9 00 

8-54 
8.10 
7.67 
7.26 
6.86 
6.48 
6.11 
5-76 
5.42 
5.09 
4.78 
4.48 
4.18 
3 90 
36; 
3.36 
3.10 
2.84 
2-59 
2.35 
2.11 
1.89 
1.67 
1.47 
1.28 
1. 12 



English 
Life 
Table 
No. 3 
(Males). 
Expecta- 
tion of 
Life. 



10.82 

10.32 

9-83 

9 36 

8.90 

8 45 
8.03 
7.62 
7.22 
6.85 
6.49 
6.15 
5.82 
5.5i 
5-21 



■93 
.60 
.41 
17 

■95 

73 

53 

•34 

16 

3.00 

2.84 

2.69 

2 55 
2.41 
2.29 

2.17 



Rules for the Calculation of Life Expectation. 

The following simple rules are taken from the " Agents Manual of Life 
Insurance." They are approximately correct. 



RULES. 

From 14 to 26, inclusive, deduct the age from 100 ; half the balance is the Expectation. 
" 26 to 30, " " 98 ; " 

" 31 to 40, " " " 96 ; " 

" 41 to 50, " " " 92 ; " " " 

" 51 to 60, " " 90 ; " 

Or, deduct the age of the party, whatever it may be, from 80, and two- 
thirds of the difference is the average expectation ; for example, if the 
age be 43 ; 80 — 43 = 37 ; ^ of 37 = 24%, the approximation average ex- 
pectation, as given in the Carlisle Table. 



34 



The Life Insurance Examiner. 



In Individual Cases, it must be remembered that a single expect- 
ation of life may be increased by the mere fact that the applicant, although 
in the line of hereditary taint, has passed the age when such tendency is 
likely to develop. The foregoing tables do not reveal this fact, which 
should be applied for the benefit of the insurable. 

For example, where there is plainly an inherited tendency to phthisis 
— where parents, or brothers, or sisters have died of the disease before the 
age of twenty-five or thirty — and the party has lived and is now in good 
health at the age of forty, one-half of the danger may be said to have 
passed ; at fifty, three-fourths ; and at sixty, not over one-fifteenth of pre- 
disposition remains. 

On the other hand, the tendency to gout, urinary diseases, insanity, 
apoplexy, paralysis, etc., increases with advancing years. 

Thus, it is plain that an individual case may be an exception to the 
average expectation, either in favor of or against the acceptance of the 
candidate for insurance. 

MALE OR FEMALE. 

The annexed table shows the proportion of male deaths to one female 
death, in city and country, at different ages : 



Quetelet's Table. 



\GE 


Male Deaths 

to One 
Female Death. 


AGE. 


Male Deaths 

to One 

Female Death. 




Percent- 
age. 
City. 


Percent- 
age. 
Country. 


Percent- 
age. 

City. 


Percent- 
age. 

Country. 




1-33 
1-33 
1-37 
1.22 
1.24 
1.06 
1.06 
1. 00 
.90 
.82 


I.70 

1-37 
T.20 
1. 21 
1. 16 
I.03 

•97 
.94 

•93 

• 75 




•93 

T 1A 


.92 
I. II 


o to i month 


21 tO 26 " 


i to 2 months 


26 to 30 " ' t nn 


.86 


2 to 3 " 


30 to 40 " • 


.88 
1.02 
1.07 

.96 

• 77 
.68 


.63 

.S3 

1. 18 


3 to 6 " 


40 to 50 " 


6 to 12 " 


50 to 60 " 




60 to 70 " ' 


1.05 
1. 00 


2 to 5 " 

5 to 14 " 


70 to So " 


80 to IOO " 


.92 


14 to 18 " 







MARRIED OR SINGLE. 

As a rule, it may be considered that married people are the most 
desirable risks, because not only are their habits of life apt to be more 



The Life Insurance Examiner. 35 

regular, but the married relation in itself, if properly carried out, is con- 
sidered more conducive to good health than the single state. The race of 
the applicant possesses a marked influence upon this rule, since in some 
rages, notably that of the Hebrew, a large proportion of deaths among 
their married women occur from parturition and its attendant complications ; 
and though it is usually considered that married women are better risks 
than single, yet, in the Hebrew race, the single are without doubt prefer- 
able. Among men, however, there is comparatively little difference as 
regards fatality between the married and single men, and it should there- 
fore not be considered a matter of great importance. In regard to women, 
furthermore, the statistics of life insurance show that if a woman is married, 
the risk is proportionately greater until she reaches the menopause, so that 
many companies charge a higher rate for their insurance during this period. 
Women who have borne at least one child without difficulty are better 
risks than primiparse. The Examiner should be careful to elicit the 
answers to the following questions, which are to be proposed to the female 
applicant in addition to those contained in the regular form of application : 

To be Answered when the Person Examined is a Woman. — A. Has she any menstrual 
disorder, or history of uterine or ovarian disease, or has she suffered abortions or serious troubles in 

labor ? B. Has she borne children ; and if so, how many and how recently ? 

C. Is she now pregnant ? D. Has she had any disease or tumors of the breast ? 

E. Has she passed the climacteric ? 

GENERAL APPEARANCE. 

Examiners of considerable experience and observation place due con- 
fidence in the conclusions deduced from a close survey of the general 
aspect of the applicant — his presence, gait, manner, voice, etc. And many 
of them might be at a loss to give a reason for their belief, which would 
nevertheless be entitled to much respect. The knowledge of human nature 
is of great service in an examination. 

THE NORMAL TEMPERAMENTS. 

Temperament is a particular state of the constitution depending upon 
the relative proportion of the different masses of the human body, and the 
relative energy of its different functions. It has generally been observed 
from the standpoint of physiology and pathology, rather than from that 
of anatomy, and the classifications of temperament are founded on the 
distinct influences of the stomach, the lung's, the liver and the brain, either 
of which predominating gives its peculiar conformation and characteristics 
to the body. Under this arrangement we have 

FOUR TEMPERAMENTS. — I. The Lymphatic Temperament, depending on 
the predominance of the stomach, being characterized by roundness of 
form, repletion of fat, softness of the flesh, a weak pulse and a languid 



36 The Life Insurance Examiner. 

condition of the general system. The complexion is pale, the hair generally 
light, and the eyes light and dull. II. The Sanguine Temperament, depend- 
ing upon the predominating influence of the arterial system, is indicated by 
a moderate plumpness of parts, tolerably firm muscles, light or chestnut 
hair, blue eyes, a strong, full pulse and an animated countenance. Persons 
with this temperament are ardent, lively and impressible, and possess more 
activity and energy than those possessing the lymphatic. III. The Bilious 
Temperament, having the liver for its basis, has for its external signs black 
hair, a dark yellowish skin, black eyes, firm muscles and angular forms. It 
indicates great activity, energy and power. IV. The Nervous Temperament 
is determined from the preponderance of the nervous system, and is 
marked by light, thin hair, slenderness of form, delicate health, general 
emaciation, rapidity of muscular action and vivacity in sensation. It 
imparts great sensibility and mental activity. This classification has a 
pathological signification — the lymphatic and nervous temperaments being 
really morbid and not healthy states of the constitution. We therefore 
prefei to base our arrangement upon an anatomical and normal foundation 
as follows : There are in the human body three grand classes of organs, 
each having its special function in the general economy ; namely, the 
motive or mechanical system ; the vital or ?uitritive system, and the mental or 
nervous system. 

In accordance with this doctrine, there are three temperaments, deter- 
mined by the predominance of the organs from which they take their name. 
The first is marked by a superior development of the osseous and muscular 
systems, forming the locomotive apparatus. In the second, the vital organs, 
the principal seat of which is in the trunk, give the tone to the organization. 
Over the third, the brain and nervous system exert the controlling power. 

The Motive Temperament. 

In the motive temperament the bones are comparatively large and 
generally long, and the form manifests a tendency to angularity. The 
muscles are only moderately full, but dense, firm and possessing great 
strength. The figure is generally tall, the face long, cheek bones high, 
front teeth large, the neck long, shoulders broad, and chest moderately 
full. The complexion and eyes are generally dark, and the hair dark, strong 
and abundant. The features are strongly marked, the expression striking 
and sometimes harsh and strong. The whole system is characterized by 
strength and toughness, and is capable of great endurance. This tempera- 
ment is generally prevalent and strongly marked among North American 
Indians, and is very common in Scotland, Ireland, Wales and France. In 
America, the States of Vermont, Maine, Kentucky, Tennessee, Missouri 
and Arkansas are noted for its development. It prevails in mountainous 
regions. 



The Life Insurance Examiner. $j 



The Vital Temperament. 

This temperament, depending upon the predominance of the vital 
organs occupying the great cavities of the trunk, is necessarily expressed 
by* breadth and thickness of body, rather than length. Its prevailing 
characteristic is rotundity. The chest is full ; the abdomen well developed ; 
the limbs plump and tapering, and the hands and feet relatively small. 
The neck is short and thick, the shoulders broad, and the head and face 
inclining to roundness. The complexion is generally florid, the eyes and 
hair light and the expression of the countenance pleasing. Persons of this 
temperament are both physicially and mentally active, love fresh air and 
exercise, but are not inclined to sedentary pursuits and hard work. Phren- 
ologically, this temperament is noted for great animal propensities. An 
undue preponderance of the absorbent system, and a sluggish action of the 
circulatory organs, produce the lymphatic temperament which is denoted 
by bodily and mental languor, sloth and apathy. 

The vital temperament is the prevailing one in Germany, Holland and 
England, and in low countries and valleys generally ; also among negroes. 

The Mental Temperament. 

The mental temperament, depending upon the predominance of the 
brain and nervous system, is indicated by a frame relatively slight and a 
head proportionately large ; an oval or pyriform face ; a high, pale forehead, 
broadest at the top; delicately cut features; an expressive countenance; 
fine, soft hair ; a delicate skin, and a high-keyed, flexible voice. The figure 
is often elegant and graceful, but seldom striking or commanding. It is the 
morbid development of this temperament, unfortunately very common in 
this age and country, which corresponds with the nervous temperament of 
the pathologists. It is characterized by emaciation of muscles, weakness 
of body, intensity of sensation and a morbid impressibility. The founda- 
tion for this perverted condition is laid in the premature and disproportion- 
ate development of the nervous tissues, and built up by sedentary habits, 
the immoderate use of tea, coffee, tobacco, stimulants and other hurtful 
indigencies. It is the prevailing temperament among scholars everywhere, 
especially in Ireland, France and America. 

Balance of Temperaments. 

Where either of the temperaments exists in excess, the result is necessa- 
rily a departure from symmetry and harmony both of body and mind, the one 
always affecting the character and action of the other. Perfection of consti- 
tution consists in a proper balance of temperaments, and whatever tends to 
destroy this balance should be avoided. By observation the impoitant 
matter of temperament may be decided at a glance. 



3$ The Life Insurance Examiner. 



OTHER PHYSIOLOGICAL CONDITIONS. 

(DUALITY is the next physiological condition to be noted in the general 
appearance. Density gives weight and strength. Porous, spongy sub- 
stances are light and weak. The lion is strong because his muscles, liga- 
ments and bones are dense and tough. It is the same in man as in beasts, 
in brain as in muscle. Great vitality can exist only where a compact brain 
is combined with strong nerves and a dense, tough, firmly-knit body. High 
quality is essential to the highest order of power in mind or body. 

HEALTH is the composite physiological condition always so prominent 
in the general appearance, when it exists. Its external manifestations are 
unmistakable. 

Respiration is one of the most important functions of the animal 
economy. Breath and life are one. The power of respiration depends 
on the relative size of the chest and health of the lungs, the state of 
the general health modifying it under all circumstances. The signs of 
good breathing power, in addition to a deep, broad chest, are consider- 
able color in the face, warm extremities, elastic movements and general 
vigor. Where it is deficient, there is general pallor, with occasional flushing 
of the face, cold hands and feet, blue veins, and great liability to colds and 
coughs. 

Circulation" is closely related to respiration, and the heart and lungs 
co-operate harmoniously in the work of manufacturing vitality. Between 
the heaving of the chest and the beating of the pulse, there is a definite 
rhythm both in strength and rapidity. The signs of a good circulation are a 
healthy color in the face and body, warm extremities and a slow, strong^ 
steady pulse. 

DIGESTION depends upon the condition of the digestive organs and the 
assistance of the circulation and respiration. 

A good development of firm, solid flesh and a healthy color are signs 
of sound digestive organs. Emaciation, paleness, a sallow or pimpled skin. 
and a feverish and desponding state of mind, are indications of deranged 
digestion. 

Activity is mainly a matter of temperament and is greatest where the 
motive and mental temperaments are both strongly developed. Its indica- 
tions are length of body and limb, with very moderate fullness of muscle. 
The deer, the greyhound and the racehorse illustrate the fact that activity 
and ease of action are associated with length and slenderness of structure. 

Excitability is another condition depending upon combination of 
temperaments and has its greatest normal manifestations in those possessing 
a full development of the vital and mental temperaments. It is morbidly 
active in persons whose nerves are disordered and whose systems are 
pervaded with the stimulation of liquor, tobacco, and strong tea and 



The Life Insurance Examiner. 



39 



coffee. In the lymphatic temperament, there is the opposite condition, a 
general coldness and apathy, which nothing seems to arouse. 

Balance of these Physiological Conditions is essential to a 

healthv state of mind and body. 

> 

The Abnormal Temperaments. 

As a general rule, each individual presents a combination of these 
temperaments, which must be determined by the judgment ot the Exam- 
iner, in order to decide any particular proclivity to disease. In those races or 
families in which marriage with outsiders has been restricted, almost typical 
specimens of the normal temperaments are found. But in this country diverse 
nationality and parentage render it more and more difficult to establish 
these boundaries. According to age, the child approximates the sanguine 
or vital temperament; the mature adult, the bilious; while advancing 
age produces a tendency either to excess of the nervous or phlegmatic 
elements. 

Disease Tendency. — Each temperament has a peculiar liability to 
certain forms of disease, more especially when any hereditary or acquired 
predisposition exists, or when the habits, occupation, residence, etc., of the 
applicant render him liable to the exciting causes of disease. 

The Sanguine Temperament predisposes to miasmatic diseases, typhoid 
and remittent fevers, the exanthems, to acute rheumatism, organic and 
functional diseases of the heart and arteries, to hemorrhoids, and to tuber- 
culosis, if nutrition is defective ; in fact, to all acute inflammatory diseases. 

The Phlegmatic Temperament, or the lymphatic, as some denominate it, 
predisposes to chronic inflammations, dropsies and fluxes of various sorts, 
especially from mucous membranes, influenza and scrofula. Dyspepsia is 
a common symptom. The power of assimilation is usually feeble, the skin 
pale and the blood-making capacity small. These defects tend to struma, 
consumption, heart and kidney affections. 

The Bilious Temperament affords soil for endemic diseases, low fevers, 
derangements of the liver and stomach, dysentery, hemorrhoids, fistula. 
Heart complications occur with rheumatism. 

The Nervous Temperament favors the occurrence of nervous diseases, 
insanity, epilepsy, paralysis, any of the neuroses, apoplexy, etc. Typhoid 
fever is apt to be fatal to this class. 

The Countenance. 

From the aspect of the countenance, disease can often be diagnosed by 
the careful observer. 

The Tuberculous Cachexia is associated with a delicate paleness and 
circumscribed flush of the face, thin features, long eye-lashes and pearly 
conjunctivae. 



4 o The Life Insurance Examiner. 



The Cancerous Diathesis is denoted by a sallow, anaemic hue, marked 
with wrinkles of the face, indicative of physical pain. 

Liver Diseases are apt to impart a yellow tinge to the complexion. 

Kidney Affections are indicated by a sodden or waxy skin, puffy eye- 
lids and a stolid countenance. 

Heart Hypertrophy lends an unnatural fullness and congestion of 
the face, which is also occasioned by habitual intemperance, with the 
characteristic injection of the conjunctivae. 

Wasting Diseases, either local or general, give a wasted, painful 
aspect to the countenance. 

Insanity is indicated by rapid change of expression, furtive glances 
of the eye, a staring, or unsteady look. 

Paralysis is indicated by impaired motion, or by disordered move- 
ments. 

Softening of the Brain renders the expression of the face dull, 
listless and vacant ; the eyes languid and heavy. 

Complexion. 

The hue of -the complexion often draws attention to the presence of 
disease in distant organs. Persons living an out-of-door life are bronzed by 
exposure to the weather, but an unnatural color frequently results from' 
disease. Residence in a malarial district superinduces a peculiar sallowness. 
Addison's disease of the supra-renal capsules is marked by a singular 
bronzed appearance. Intemperance and cardiac affections cause undue 
congestion of the skin, and there is often a livid complexion resulting from 
imperfect aeration of the blood. Incipient tuberculosis is characterized by 
lividity, with circumscribed evanescent flushes, while anaemia and albu- 
minuria are characterized by a pallid and sodden appearance. 

Hair and Eyes. 

This is of little significance except as a mark of identification, but still it is 
well for the Examiner to note the condition of the hair, whether it has fallen, 
or turned gray prematurely and without hereditary influence, as it may pos- 
sibly lead to the supposition either of pre-existing syphilis or some cachexia 
due to a wasting disease. It is also well to remember that individuals 
having light, or sandy hair, are supposed to be more frequently affected 
with diabetes. 

In regard to the eye, we have to note both the condition of the pupil 
and its expression. In regard to the former, whether it is dilated or con- 
tracted, or whether arcus senilis exists ; whether there is projection, as 
found in disease of the heart ; whether there is oedema of the lower lids, in- 
dicative of renal disease; whether the expression due to insanity is present, 



The Life Insurance Examiner. 4* 



or the peculiar pearly appearance of the conjunctivae due to consumption 
or anaemia. 

Figure. 

^he Examiner should note the physical proportions of the applicant ; 
first, as to whether the applicant is compact or spare, thickset, corpulent or 
emaciated. Note whether the body is disproportionately long or short com- 
pared with the limbs. Usually a long trunk indicates endurance and 
strength. Emaciation should lead the Examiner to suspect phthisis or other 
wasting disease ; and the size of the bones should be taken into consideration, 
as applicants having large bones and muscles are apt to be possessed of 
great endurance, and strong muscular structure and muscular development 
are always more desirable in a risk, owing to the fact that it is an index of 
assimilation and good health, and should rather predispose the Examiner 
in favor of the applicant. 

Race. 

The Examiner should inquire of the applicant his nativity and the 
nativity of his parents. 

The comparative mortality of different races is a topic of increasing 
interest. We append some facts from insurance reports. 

Of the whole mortality, in over 5000 cases, those born in the United 
States give 75 per cent ; Germany, 9^ ; Ireland, 4j£ ; England, 4^ ; 
Scotland, ij£ per cent. Total, United States, 75 ; Foreign born, 25 per 
cent. The fact of nativity seems to have very little influence on the cause 
of death, there being but slight variation from the 75 per cent for most of 
the diseases. 

The following are exceptions. In typhoid and malarial fevers, diar- 
rhoea, cholera and pneumonia, the percentage of the United States rises 
above 80 ; and in cancer, alcoholism, dropsy and peritonitis, it falls below 
70 per cent. 

Alcoholism. The deaths from this cause are chiefly among foreigners, 
in the following order: England, Ireland, Scotland and Germany. 

Consumption varies considerably. It gives the largest proportional 
mortality among the natives of Ireland and the smallest among the 
English. 

Apoplexy gives the largest percentage among the Scotch, and the 
smallest among the Irish ; and the same ratio is true of nervous diseases 
generally. 

Cancer. The foreign born give a much higher mortality from cancer 
than native Americans — 35.17 per cent, instead of the usual average of 25. 
Among foreigners, the Germans give the highest proportion, and the Scotch 
the lowest. 

Heart disease prevails uniformly among different nationalities. 



A2 



The Life Insurance Examiner. 



Digestive diseases. Ireland gives the largest percentage for diseases of 
the stomach, and the smallest for diseases of the bowels. 

Kidney diseases are more fatal among the Scotch. 

Accidental deaths occur equally among all races. 

Suicides are equally frequent among the native born, the Germans and 
the English. The Irish and Scotch afford very few instances. 

The tables relating to deaths among persons of other nationalities are 
too few to form a basis for calculation. 

The comparative mortality of the white and colored races is given in 
the following tables, compiled from the Census Report, and the two last on 
the authority of Dr. W. A. Hammond : 

Showing the Comparative Mortality of Whites and Blacks in 

the United States, from Diseases Mentioned in the Life 

Insurance Applications, for the Year 1S50. 



CAUSES OF DEATH. 



Ap jplexy 

Asthma 

Bronchitis 

Cancer 

Consumption 

Colic 

Diphtheria 

Diseases of the heart. 

Dropsy 

Fits (epileptic) 

Fistula 

Gout 

Intemperance 

Insanity 

Influenza . 

Liver complaint 

Paralysis 

Palpitation 



Quinsy 

Rheumatism 

Rupture 

Scarlet fever 

Spitting of blood. , 

Diseases of urinary organs. 
Syphilis 



Number of Deaths. 


Ratio in ioo.ooo Deaths. 


White. 


Colored. 


White. 


Colored. 


10,184 


944 


iS,69i 


10,107 


926 


258 


1,699 


2.762 


6,722 


2,094 


12,337 


22,420 


3,179 


346 


3.834 


3,704 


70,893 


7,771 


130. 117 


S3, 203 


1,529 


9 


2,806 


96 


7,662 


849 


14,062 


9,000 


13,891 


4,766 


25,495 


51,029 


1,074 


202 


1,971 


2,162 


26 


7 


47 


74 


79 


5 


144 


53 


i,792 


177 


3.289 


i,895 


574 


91 


1,053 


974 


34i 


144 


625 


1. 54i 


3,211 


294 


5.893 


3,147 


1,284 


313 


2,356 


3.351 


1,500 


363 


2,753 


3-886 


367 


149 


673 


1 695 


23 721 


1,681 


43.537 


17,998 


3oo8 


276 


6,068 


2,972 


657 


149 


1,207 


i,595 



Note. — The blank spaces indicate tru-t the diseases opposite them are regarded as symptoms merely. 



The Life Insurance Examiner. 



43 



In the following table is given the total death rate per iooo, and also 
the death rate under five years of age, in Charleston, S. C. ; Savannah, Ga. ; 
Nashville and Mempis, Tenn., for the years 1883-85 : 



^ , . 


Charles'on. 


Memphis. 


Nashville. 


Savannah. 


White 


1883. 
2l.6o 
47.13 


1883. 

15 19 

35.83 


1883. 

18.68 
31.29 


1883. 
20.47 




39-57 




Acoreerate 


34.92 

1884. 

23. 6S 
44- 63 


22.50 

1884. 
18.80 
41.66 


23.50 

1884. 
1677 
26.94 


30.02 


White 


1884. 
19-54 
42.21 


Colored 


Aersrresrate 


34-55 

1885. 
17.64 

38-49 


26.90 

1885. 
16.56 
36.96 


21.94 

1885. 
14.69 
27.07 


30.82 


White 


1885. 
12.09 
34.04 


Colored 




Aeerresrate 


23. 8S 


23.80 


19.IO 


23.65 





Rate of Deaths Under Five Years. 



• 


Charleston. 


Memphis. 


Nashville. 


Savannah. 


White 


1883. 

5-88 

21.03 


18«3. 

3-75 
13-91 


1883. 

5.65 
12.44 


1883. 

7.59 
18.OI 


Colored 






Aggregate 

White 


13.45 

1884. 

6.48 

16.52 


8.83 

1884. 

4-47 

15.63 


9.04 

1884. 

5.46 
11-55 


12.80 

1884. 

6-54 
16 68 


Colored 






Aggregate 


II.50 

1885. 

4-45 

14.38 


10.05 

1885. 

4.67 

13.46 


8-SO 

1885. 

4-37 

10.78 


11 61 


White 


1885. 

4-23 

13.70 


Colored 






9.41 


9.06 


7-57 


8.96 





44 



The Life Insurance Examiner. 



Table Showing the Comparative Mortality of White and Black 
Troops from Consumption at Several of the British 
Military Stations, as it Occurs from Year 
to Year (Hammond). 



Ratio of Deaths in ioco. 



STATION. 



Jamaica 

Bahama Islands 

Honduras. . 

Sierra Leone. . . 

Mauritius 

Ceylon 

Gibraltar 



White Troops. 


Colored Tioops. 




10.3 


6.0 


9-7 


3-0 


S.i 


6.0 


6-3 


4.0 


12.9 


4Q 


10.5 


5-3 


4-3 



Table Showing the Comparative Mortality from Malarial 
Diseases of White and Black Troops, from 1S18 to 1836 

(Hammond). 



station. 



Jamaica 

Bahama Islands. 

Honduras 

Sierra Leone. . . 

Mauritius 

Ceylon , 



Ratio of Deaths in ioco. 



White Troops. 


Colored Troops. 


101.9 


1 2 


15.9 


5-6 


81.0 


44 


4100 


2.4 


1-7 


0.0 


24.6 


1.1 



Development. 

The Examiner should scrutinize the whole body for external defects to 
govern him in his final judgment of the risk. He should note the forma- 
tion of the head and face for indications to determine the physical stamina 
of the applicant. An examination of the trunk will show whether or not 
the curves of the spine are normal and if there is any deformity. He should 
observe the relative development of thorax, abdomen and lower extrem- 
ities ; the texture of the skin ; the presence of scars or marks of previous 
disease, which, existing on the neck, point to scrofulous taint ; on the groin, 
to syphilis ; the condition of the surface veins ; the existence of local par- 



The Life Insurance Examiner. 45 

alysis, resulting from lead poisoning or affections of the nervous system, of 
spasms and tumors ; the appearance of the hands and nails. 

The Size of the Bones and Contour of the Muscles— Strong 
bones and muscles indicate vitality and endurance. 

The Diathesis. 

Diathesis is a morbid condition, predisposing to the development of a 
particular disease, and relates to disease as temperament does to health. 
Such unsoundness of constitution may be due to deficient vitality, trans- 
mitted from parents who were too far advanced in life to produce robust 
issue, or whose vigor had been sapped by dissipations or constitutional 
diseases. It is of the nature of premature senility. In some the diathe- 
sis is inherited. Congenital syphilis, gout, scrofula, tuberculosis, cancer, 
asthma and many neuroses are apt to appear in the offspring at a certain 
age, in consequence of some inherited tendency in the blood and tissues. 

In others the diathesis is acquired, either from unwholesome surround- 
ings or the infection by some specific poisons, such as any of the zymotic 
diseases. 

The strumous diathesis is a common one, and arises from deficient and 
defective nutrition, ending usually in scrofulosis or tuberculosis. Impair- 
ment of assimilation and function characterizes this diathesis. 

The gouty, or rheumatic diathesis, is becoming very frequent in this 
age of high living and habits. In it there is a predisposition to the undue 
formation of uric acid, to congestions, irritation or inflammation of the 
muscular and sero-fibrous tissues of the vascular systems, serous mem- 
branes and the peritoneum, which develop speedily into gout and rheuma- 
tism without proper treatment. 

The adipose diathesis is self-evident, and there are many others pre- 
monitory of well-known diseases. 

The Cachexia. 

The cachexia is a chronic state of ill health, which may not be due to 
disease of any organ, but dependent upon a depraved state of the blood. 
It rather signifies the morbid constitution, which is the disease, and it may 
precede any local manifestation of the latter. Thus we may have the cancerous 
cachexia, culminating in malignant disease of any organ ; the tuberculous, 
ending in pulmonary tuberculosis, etc. When the cachexia supervenes upon 
the diathesis, the prognosis becomes grave, but this is not always the 
case. Other cachexias are the syphilitic, erysipelatous, anaemic, chlorotic, 
rachitic, etc. 

Blindness. 

Either partial or complete blindness, involving as it does the constant 
risk of accident, should debar from life insurance. The extent of the 



4 8 The Life Insurance Examiner. 

the persons, and subscribe of his own knowledge to this important factor. 
And the same precaution applies to height. 

Height. — The maximum of height is usually attained at the age of 
twenty-five, the rate of increase being ten inches between the ages of eleven 
and eighteen, and but two inches from that age to maturity. When the 
increment of the latter epoch exceeds two inches, it is indicative of a cor- 
responding exhaustion of the nutritive powers and militates against the 
chances of long life, as a general rule. 

Average height of adult males in America is five feet eight inches ; of 
adult females, about five feet two inches. Emigrants from Europe average 
under five feet six inches, with the exception of Sclavs, Poles and Hun. 
garians, who equal the American standard of height. Five feet seven inches 
is the mean for emigrants from the British Islands. In the United States, 
the height of the country people is said to be above that of the city bred, 
while in Europe the reverse is true ; which shows that the favoring influ- 
ences of hygienic surroundings are variable in different people and places. 

EXTREMES OF HEIGHT. — Very tall men are commonly defi "t in mus- 
cular and respiratory power, and suffer a tendency to diseases of the neart and 
lungs. They are more subject to rupture, varicose veins and chronic ulcers of 
the lower extremities. When suffering from acute affections, a chronic form 
of the same disease is likely to supervene and break down the constitution. 

Very short ifiend.ro. apt to suffer from lack of development and vitality, and 
fall easier victims to acute and epidemic diseases. The downward range from 
the average height is safer than the upward, provided the organs of respira- 
tion, circulation and innervation are in a normal condition, because the small 
person is more easily nourished and is not as apt to overtax his strength. 

In persons exceeding the average stature, one often finds a develop- 
ment of bone and muscle at the expense of the vital internal organs, with 
the consequent deterioration of life expectation. 

WEIGHT. — The average weight among males varies, according to age, 
from 145 to 160 pounds. Excessive obesity at any age vitiates the risk, 
especially if it has appeared with comparative suddenness, and cannot be 
recognized as an inherited tendency in an otherwise healthy family. At 
the same time, it must be remembered that the human race is prone to cor- 
pulency after maturity, so that it may be safe to allow a discrepancy of fifteen 
or twenty pounds in either direction, from the published tables, when the 
family and personal histories are good. 

Comparative Weight of the Sexes. — At the age of twelve years the weight 
of males and females is equal, but both before and after that period the 
male exceeds the female both in size and weight. Quetelet asserts that the 
female reaches her maximum weight later in life than the male. Progressive 
increase of weight from birth to the decline of life is normal and independ- 
ent of the maturity of growth, which occurs at the age of twenty-five years. 
The later increase of weight is due to the deposit of adipose tissue under 



The Life Insurance Examiner. 



49 



the skin and within the cavities of the body. The tendencies to fatty de- 
generations and apoplexy must not be overlooked. Sedentary occupations, 
with an ample food supply, cause increase of weight. 

Diminution of weight ensues from active muscular exercise in the 
open air, accompanied by a restricted diet. Local emaciation points to 
incipient phthisis, and is denoted by wasting of the thorax and bones, 
before it is noticeable elsewhere. 

Sudden changes of weight demand careful consideration, and are more 
untoward than habitual departures from the normal standard. The rapid 
occurrence of corpulence suggests an abnormal state of nutrition, as would 
result from sedentary habits, intemperance and internal organic diseases. 
Rapid emaciation denotes the approach of some form of wasting constitu- 
tional disease. 

Relative Height and Weight. — A normal variation of twenty per 
cent is allowable under favorable conditions. Dr. Brinton says: "An 
adult male in good health, five feet six inches high, ought to weigh 
rather rnf'.'n than 140 pounds, and for every inch above or below this height 
we mayadd or subtract five pounds." 

Relative Chest Measurement. — This indicates the proportions of height 
to weight. Brent's rule, measurements to be made over the nipples, is the 
standard. 

Irrespective of height, the circumference of the chest increases one inch 
for every ten pounds increase of weight. 

Maximum CJiest. — Two-thirds of the stature equals the circumference 
of the chest. 

Medium Chest. — Half of the stature plus one-fifteenth of the stature, 
equals the circumference of the chest. 

Minimum Chest. — Half of the stature minus one sixty-first of the 
stature, equals the circumference of the chest. 

Tables of Proportions. 



Height. 


Weight. 


Medium Chest. 




Pounds. 
120 
125 
130 

135 
140 

143 
145 
148 

155 
160 
165 
170 


Inches. 
34o6 
35-13 
35.70 
36.26 
36.83 
37-50 
38.16 

38.53 
39.IO 
39-66 
40.23 
40.80 




* " O " « <« 


5 " 4 " " " 


5 " c " «< " 


c "6 " " " 


5 " 7 " *' " 


5 " 8 '• " " 


5 «' Q " " " 


c "10 " " " 


5 " 11 " " " 


6 " .. " " " 





5o 



The Life Insurance Examiner. 



Persons over forty years old may be allowed an increase of about two 
pounds for every inch above five feet, as follows : 



Height. 



5 feet r inch. 



2 inches 

3 " •• 

4 " •• 

5 " •• 

6 " .. 



Pounds. 



127 

134 
141 
14S 

155 
162 



Height. 



5 feet 7 inches 
5 " 8 •• 
5 " 9 " 
5 " 10 " 

5 " n " 

6 " .. «« 



Pounds. 

169 
176 

183 
190 

197 
204 



The following table gives the over and under-weight limits ; and if the 
applicant is either above or below the figures here stated, he should be 
rejected by the Examiner, unless his physique be unusually excellent, or 
it be an hereditary trait. In either case the Examiner should state the 
reasons for his acceptance very fully. If the condition be temporary, the 
applicant should be postponed. 



Height. 



5 feet 

5 
5 

5 
5 
5 
5 
5 
5 
e 

5 
5 
6 
6 



inch. . 

inches 



Chest. 



Inches. 
33'A 
34 
35 
36 

36^ 

37 

37'A 

38 

38^ 

39 

39 X A 

40 A 

41 
4i >£ 



Standard 
Weight. 



Pounds. 
115 
120 

125 
130 

135 
140 

143 
145 
148 

155 
160 
165 

170 
175 



Twenty Per 

Cent Under 

Weight. 



Pounds. 

92 

96 
100 
104 
10S 
112 

114 
116 

H9K 

124 

128 

132 

136 

140 



Forty-five Per 

Cent Over 

Weight. 



Pounds. 
167 
174 
181^ 
188^ 

195 
203 
207 
2IO 
215 

224K 
232 

239 
246 

254 



EXAMINATION OF THE CHEST. 



SINCE so large a proportion of the deaths in adult life occur from puU 
monary and cardiac diseases, it is especially important that the 
Examiner should exercise great care in the physical exploration of 
this region of the body. 

It is not always that an applicant can be examined in a physician's 
office, or in the office of the company. Very frequently the exigencies of 
business require the examination to be conducted in his own place of 
business, where it is simply impossible to have his clothing removed, so that 
the Examiner is often called upon to make a thorough examination with- 
out having an applicant entirely stripped, and the author would suggest the 
plan shown in the accompanying engraving as being available at all times 
and in all places, and as one also to which the applicant is not liable to 
object. Direct the applicant to remove the coat and vest, and then drop 
the suspenders. He is then to release his shirt, which is to be rolled up as 
far as possible, and held directly under the chin by the hands of the appli- 
cant himself. This method is expeditious and satisfactory to the applicant, 
who usually objects to undergoing the discomfort of removing all his cloth- 
ing above the waist. 

EXAMINATION OF THE LUNGS. 

A well-developed thorax is usually considered an indication of vital 
capacity and endurance. Respiration may be defined as a mechanical, 
involuntary process, consisting of inspiration and expiration. 

Residual air is the term applied to that portion which cannot be 
expelled from the lungs by the most forcible expiration. 

Supplementary ', or reserve air, can be expelled by forcible expiration. 

The breathing, or tidal air, is the portion used in ordinary respiration. 

The complementary air is that portion which can be inhaled by means 
of the greatest inspiration. 

The number of respirations per minute in a normal adult at rest is from 
fifteen to twenty. They exceed this number in childhood, in high altitudes, 
and during exercise ; they are diminished in old age and by the action of 
certain medicines and diseases. 

There is a constant ratio between the rate of respiration and the pulse ; 
in health it is as one to four and one-half. Any marked deviation from this 



The Life Insurance Examiner. 



53 



proportion- should excite suspicion of some latent cause. Among females, 
youths and people of a nervous temperament, the rate of respiration is easily- 
increased by any temporary excitement. The fifth expiration has been 
observed to be a little deeper than the average. The ratio of inspiration, 
expiration and quiescence is about as five, four and one, respectively. 

Irregularities of respiration demand careful scrutiny. Prolonged ex- 
piration is usually a symptom of local lung lesion. Irregular, intermittent 
or jerking respiration indicates nervous derangement. 

The type of respiration should be abdominal in the infant, diaphragm- 
atic and inferior costal in the adult male, and superior costal in the adult 
female. Note carefully any change of type. Pectoral breathing, especially 
in the male, with rising of the shoulders, denotes pulmonary disorder. 

Respiratory Power and Vital Capacity. — These are synonymous 
terms. Dr. Hutchinson has compiled the following table showing the vari- 
ous degrees of respiratory power : 

Table of Respiratory Power. 

Inspiratory Power. Expiratory Power. 

\y 2 inches is weak 2 inches. 

2 " "ordinary 1%. " 

iy 2 " "strong 3 l A 

3% ■• " very strong 4^ 

4^ ** "remarkable Ss " 

Respiratory Power, Height and Weight. 



Height. 



Under 5 feet 

5 feet o inch to 5 feet 1 

5 *« I » " 5 " 2 

5 " 2 " " 5 " 3 

5 " 3 " " 5 " 4 

5 " 4 " " 5 " 5 

5 - 5 " " 5 " 6 

5 " 6 " " 5 " '7 

5 " 7 •« " 5 " 8 

5 •' 8 " " 5 " 9 

5 " 9 " " 5 " 10 

5 " 10 " " 5 " 11 

5 " 11 " " 6 " . . 

Over 6 feet 



inch, 



Respiratory- 
Power — 
Cubic Inches. 


Weight- 
Pounds. 


135 


92.26 


175 


115.52 


177 


124-33 


189 


127.86 


193 


138.01 


201 


139-17 


214 


144-93 


229 


144.29 


228 


152.59 


237 


157.76 


246 


166.40 1 


247 


170.86 


259 


117.45 


276 


218.66 



The mean for all heights being 217 cubic inches. 

The second table, which was also compiled by Dr. Hutchinson, shows 
the mean vital capacity of 1923 men. 

A man five feet eight inches high should have a breathing capacity 
of about 230 cubic inches of air, although during tranquil respiration the 



54 



The Life Insurance Examiner. 



tidal air does not amount to more than thirty cubic inches. For every inch 
of stature between five and six feet, eight additional cubic inches of air are 
given out by a forced expiration. This proportion should be maintained. 

The spirometer is used to verify these tests, and it would be a useful 
piece of furniture in the examining room. 

The extreme breathing capacity is less in women than in men, and less 
in childhood than in adult life. It is diminished by obesity. Its volume 
increases with age to the thirtieth year, and gradually decreases to the de- 
cline of life. At the age of sixty-six years, it is computed that there is a 
diminution of four-fifths from the maximum rate. 

In some cases there is diminished vital capacity, combined with unmis- 
takable muscular strength ; and again others show extraordinary breath- 
ing capacity. The discrepancy is due to lack of exercise and practice. 

Mensuration of the Chest. 

In mensuration, an ordinary tape line is sufficient for the purpose of 
life insurance examinations. To measure the circumference of the chest, a 
spinous process of one of the vertebrae is chosen as a fixed point, and the 
tape is then passed around the body to the same point, a line just above 
the nipple being the best for this purpose. It should be noted whether the 
distance from the spinous process to the median line anteriorly is the same 
on both sides ; and the measurements of the chest during full inspiration 
and expiration, as also the average measurement, should be taken. 

It must be borne in mind that, even in health, the measurement of 
the two sides is apt to vary, right-handed persons being on an average 
half an inch larger on the right side. In taking the chest measurement, 
the Examiner should be careful to measure next the skin, and should 
take the greatest, medium, and least expansion. The difference between 
the greatest and least expansion is usually considered to indicate the degree 
of vitality. 

Consumptives, by the records of the Mutual Life, have an average 
measurement of one and one-half inches less than non-consumptives, and a 
disproportionately small chest measurement should be considered sus- 
picious. 

The measurements should be taken at a little above the navel in 
males, and a little above the mammae in females. The extreme between 
inspiration and expiration, however, can be greatly increased by systematic 
exercise, it being possible for a man of comparatively slight physique to so 
habituate himself by constant practice to expansion of the chest, that the 
difference between the expiration and inspiration will be markedly beyond 
the average, while, on the other hand, it is often seen that persons of 
powerful physique and strong constitutions have comparatively little differ- 
ence in the measurements of inspiration and expiration, owing to entire lack 



The Life Insurance Examiner. 55 



of practice ; so that great expansion cannot be accepted in all cases as 
being indicative of vital capacity, although in ordinary cases it is not without 
its value. 

Allen states that " it is well to bear in mind that due proportion requires 
that the circumference should equal twice the distance between the angles 
of the shoulders, that it should be four times the antero-posterior diameter 
at the lower portion of the sternum, and that this latter diameter should 
equal the distance between the nipples." 

The expansion and capacity of the chest are diminished in obese indi- 
viduals. They are also less in females and in children than in adult males, 
and increase with age to the thirtieth year, gradually decreasing from this 
to the decline of life. 

The average expansion is a little over three inches when the inspiration 
is a forced one, but in ordinary breathing it is scarcely more than an inch, 
the right side expanding a little more than the left. 

Regions of the Chest. 

The surface of the chest is divided, for convenience sake, into the an- 
terior, posterior and lateral surfaces. 

The anterior surface is subdivided into the upper region, extending 
from the fourth rib to just above the clavicle, and the lower region, extend- 
ing from the fourth rib downward. 

The posterior divisions are the same. 

For convenience, also, we designate the space between the two scapulae 
as the inter-scapular space, and the spaces just above and below the clavicle 
as supra and infra-clavicular spaces. 

METHODS OF EXAMINATION. 

The examination of the chest is conducted by means of, first, inspec- 
tion ; second, palpation ; third, percussion ; fourth, auscultation ; fifth, 
mensuration. 

Inspection. 

Note the size, form and movements. The size of the chest can only be 
judged accurately by mensuration, but it can be approximately divined by 
the eye. 

MOVEMENTS. — It should be noticed that the two sides of the chest are 
to a great extent symmetrical in movement, both sides rising equally during 
inspiration and sinking during expiration, the motion of inspiration being 
longer than that of expiration, and the interval between them extremely 
slight. This movement is called the respiratory movement and is visible 
over the whole thorax; in males, more distinct at the lower portion of the 
chest, and in females, at the upper. The number of respirations in health 
varies from sixteen to twenty to the minute ; but, in certain pulmonary 
affections, these numbers are greatly exceeded, although increased fre- 



56 The Life Insurance Examiner. 

quency of breathing can occur independently of disease of the lung, as when 
the diaphragm does not descend ; and when this is found to be the case, it 
should lead to an examination for abdominal tumors, or dropsy, or adhesions 
caused by peritonitis. If the motions of the chest be very slow, cerebral 
disease should be suspected ; in such cases the breathing tends to be alto- 
gether abdominal. 

If the movements of the chest are plainly visible from one side and the 
reverse on the other, the Examiner should suspect the existence of pleurisy, 
of pneumo-thorax, or hemiplegia. 

The Form of the Chest. 

Contraction may denote a lung of diminished size, due to chronic 
change in its tissues, or to tubercle or adhesions. 

Expansion should lead the Examiner to suspect emphysema, pleuritic 
effusion, thoracic tumors, or hypertrophy of the heart. 

The form of the chest is also altered by curvatures of the spine or con- 
genital malformations, the existence of which, or a varicose condition of the 
veins on the surface of the chest, should lead the Examiner to suspect em- 
physema or tumor, or some intra-thoracic affection causing a disturbance of 
the circulation. 

Palpation. 

Palpation is to be practiced by applying the palmar surface of one 
or several fingers evenly, without too much pressure on the part of the 
Examiner. 

Palpation, or the application of the hand, is also an aid in determining 
the size, movements and form of the chest ; but, in addition, it is used as a 
means of diagnosis in determining the density and condition of tumors, the 
frequency of the breathing, the action of the heart, the state of the thoracic 
walls, and to locate tender spots. Ronchial or sonorous fremitus, which is 
the term given to vibrations produced by ronchi, may also be distinguished 
by palpation, as may also vocal fremitus. 

Palpation is also of use in detecting fluid by means of fluctuation, and 
a roughened serous membrane may be diagnosed by means of friction 
fremitus. When both fluid and air are present and the applicant is shaken, 
a distinct vibration is felt, accompanied by a splashing sound. This is 
known as succussion. 

Percussion. 

In practicing percussion, the Examiner may simply use the fingers or 
employ the hand. If the fingers are used, the palmar surface of the left 
index or middle finger should be applied to the applicant's chest, and struck 
with the tips of the fingers of the other hand. Sounds are made more dis- 
tinct by placing the applicant with his back against a door. The whole 



The Life Insurance Examiner. 57 

movement should proceed only from the wrist, and ought to be quick and 
not too forcible. 

Sounds Produced by Percussion. 

The character of the sounds should be noted with reference to the 
quality, intensity, pitch and duration. 

The varieties of percussion sound are pulmonary resonance, dullness, 
flatness, tympanitic resonance, amphoric resonance and cracked-pot 
resonance. 

1. Pulmonary Resonance. — This is a clear sound, obtained by strike 
ing over normal pulmonary tissue. In health, its quality is pulmonary, its 
duration is marked, its pitch is low, and its intensity varies in different sub- 
jects. In disease, it may be changed ; if one lung does not respire, the 
pitch is higher and the intensity greater over the other. This is also the 
case in emphysema of both lungs, and also over the lung tissue, when the 
lower portion of the thoracic cavity is filled with effusion. 

2. DULLNESS. — A dull sound denotes absence of air. In health it is 
present where the chest wall is thickened, and where the liver and heart 
are in contact with the lung, and over the heart itself. In disease it may 
be caused by pleuritic adhesions, tumors, accumulations of fluid in the 
pleural cavities, by cedema, pneumonia, hemorrhages, phthisis, by emphy- 
sema, or by hypertrophy of the heart, liver and spleen, or by aneurisms or 
abscesses. 

There are many different degrees of dullness, and it is always asso- 
ciated with an increased sense of resistance to the percussing finger. 

3. FLATNESS. — Flatness is heard over solid viscera and over the thick 
muscles of the back ; its quality is flat, its pitch is high, its duration is 
short, its intensity is not great. In diseases, if found over the lungs, it 
may be produced by very thick pleuritic adhesions, by complete consolida- 
tion of the lung, especially over adhesions, by large accumulations of fluid 
in the pleural cavities, by hypertrophy of the solid viscera, and by tumors 
and abscesses. 

4. Tympanitic resonance is a non-vesicular sound, having the char- 
acter of that obtained by percussing the intestine, and is not heard in the 
normal chest except occasionally, when it is the transmitted sound of a 
distended stomach or intestine; but in disease it is heard over the air in 
the pleural cavities, over large cavities in solidified lung, over lung com- 
pressed by fluid, and in some cases of emphysema. 

5. AMPHORIC RESONANCE is a variety or modification of the tym- 
panitic resonance. It has a sound of raised pitch, with a peculiar metallic 
quality, and is heard over large cavities in solidified lung, and over air 
in the pleural cavities. 

6. The Cracked-Pot SOUND is also a variety of tympanitic resonance, 
In order to obtain it the applicant should be made to keep his mouth open 



58 The Life Insurance Examiner. 

when percussion is made. The condition usually producing the sound is a 
cavity communicating with the bronchial tube, and it is heard over cavities 
in solidified lung and over lung compresssed by fluid. 

Percussion of the Normal Chest. 

The anterior portion of the chest affords a clearer sound than the poste- 
rior on account of the difference in the thickness of the thoracic walls. 

In the supra-clavicular regions, dullness is met with over the apices of 
the lungs. In the infra-clavicular regions, on the left side and in front, 
from the upper edge of the third rib to the lower edge of the clavicle, there 
is pulmonary resonance ; on the right side, from the top of the fourth or 
fifth rib to the lower edge of the clavicle, there is pulmonary resonance, but 
this is of a lower pitch than that of the left side. 

In the precordial region, over an area corresponding to the size of the 
heart, there is dullness, which is more marked where the heart is uncovered 
by the lung. Where the sternum covers the heart, the sound is still further 
modified by the presence of the bone. 

From the fourth rib downward, on the right side, the resonance of the 
lung, on strong percussion, becomes slightly deadened, and near the sixth 
rib, the upper edge of the liver should be indicated by the presence of a 
perfectly dull sound. During full inspiration, the dull sound begins an 
inch or so below this, owing to the liver being pushed downward by the 
respiratory effort. 

In the posterior portion of the chest, in the supra-scapular regions, 
there is dullness on percussion, increasing in proportion to the amount of 
muscle or fat possessed by the applicant. In the scapular regions the per- 
cussion sound is also dull ; and in the infra-scapular regions, from the angles 
of the scapula downward on both sides for a distance of about five inches, 
there is pulmonary resonance. Below this, the percussion line is flat, 
the line of flatness being usually about an inch higher on the right than on 
the left side. 

In the inter-scapular regions, there is pulmonary resonance on percus- 
sion ; and in the axillary, on the left side, dullness begins at the level of the 
sixth rib ; and at the level of the seventh and below, there may be either 
dullness, flatness or tympanitic resonance, but on the right side there is 
pulmonary resonance from the axilla down to the fifth rib, from which 
region there is dullness extending down to the sixth rib, where flatness is 
elicited, continuing down to the free border of the ribs. 

Auscultation of the Lungs. 

In practicing auscultation, the Examiner may use the method known as 
the immediate, by direct application of the ear to the chest, or the mediate, 



The Life Insurance Examiner. S9 



by means, of the stethoscope ; and while auscultating, he should avoid 
stooping or having the head too low. 

Over the healthy chest we hear three kinds of breathing, pulmonary, 
bronchial and bronchial-vesicular. In each of these, the inspiration and 
expiration should be noted in respect to the quality, the pitch, the intensity 
and the duration. 

1. Pulmonary Breathing. — The inspiration is of pulmonary quality, 
considerable duration, low pitch and variable intensity. The expiration is the 
same, except that it is of shorter duration ; in many healthy chests it isentirely 
absent. In the right infra-clavicular region, both inspiration and expiration 
are often of higher pitch, and the expiration is longer than over the rest of 
the chest. It should be borne in mind that there is much difference in the 
intensity of the breathing in the chests of different healthy adults 

2. Bronchial-Breathing.— This is heard over the larynx, the trachea 
and the upper part of the sternum. The inspiration is of tubular quality, 
of higher pitch, of marked intensity, and of considerable duration. The 
expiration is the same, except that it is of greater intensity and of longer 
duration than inspiration. 

3. Bronchial-vesicular Breathing can often be heard in the 
inter-scapular region ; it is intermediate in character between pulmonary and 
bronchial, while it may partake of the character of each ; in quality, it 
approaches that of bronchial or pulmonary breathing ; its pitch is higher 
than that of pulmonary, while not as high as that of bronchial beathing, 
while the expiration is longer and of higher pitch than in pulmonary 
breathing. 

Varieties of Respiration in Disease. 

1. Exaggerated, or puerile breathing, is heard over the lungs in some 
cases of vesicular emphysema. 

2. Diminished breathing is frequent in phthisis and in emphysema, and 
is heard over lungs into which less air than usual is inspired. 

3. Suppressed breathing is observed in pleurisy with effusion, intra- 
thoracic tumors, obstructed bronchi, pneumonia and phthisis, and in all 
cases where little or no air enters the lungs. 

4. Bronchial breathing is heard over consolidated and compressed lungs, 
and over cavities. In quality it is tubular or bronchial; its pitch is high, 
and its expiration longer and of higher pitch than inspiration. 

5. Broncho-vesicular breathing is heard over lesser degrees of con- 
solidation and compression of the lung, and is intermediate in its character 
between bronchial and pulmonary breathing. 

6. Cavernous breathing is heard over cavities, consolidated lung, and 
over compressed lung. In quality it is cavernous, in pitch low, and its 
expiration is longer and of lower pitch than inspiration. 

7. Amphoric breathing is heard over large cavities, and over the chest 



60 The Life Insurance Examiner. 

in pneumothorax, and resembles the cavernous except in its quality, which 
is of a peculiar musical character. 

8. Sibilant and sonorous breathings are heard in acute and chronic bron- 
chitis, emphysema and asthma, and are supposed to be caused by irregular 
contractions in the walls of the bronchi. 

Sibilant Breathing is whistling in quality, high in pitch, and the expira- 
tion is prolonged. 

Sonorous breathing is sonorous in quality, low in pitch, and in it expira- 
tion is also prolonged. 

Rales. 

The word rale is used to designate certain sounds which do not exist 
in the healthy state, and which cannot, therefore, be considered as modifi- 
cations of the normal respiration ; and nearly all of them are sounds which 
are generated in the air tubes by the passage of the air through them when 
contracted, or when containing fluid. In the first case they are termed 
dry, and in the second moist rales. They may obscure or entirely take the 
place of the natural murmurs, and they may have their seat in the upper 
air tubes or in the divisions of the bronchi. When occurring in the larynx 
or trachea, they are called tracheal rales ; and when in the bronchial tubes, 
they are called bronchial ; and as this is their most frequent location, the 
term rale means a bronchial rale, unless the location is specially indicated. 

We distinguish the crepitant, sub-crepitant, coarse and gurgling rales. 

The crepitant rale is heard in pneumonia, in phthisis and in dry pleurisy, 
and has a very dry, crackling sound, heard only at the end of inspiration, 
not in expiration. It is often necessary to make the applicant cough in 
order to develope this rale. 

The sub-crepitant rale is heard in bronchitis, pneumonia, phthisis and 
cedema of the lungs, and is a fine, moist, bubbling sound, heard both in 
inspiration and expiration. 

Coarse, mucous or bronchial rales are heard in acute and chronic bron- 
chitis and phthisis. 

Gurgling rales are heard only over small cavities, and usually in the 
bronchi of compressed lung, and are very coarse sounds having a peculiar 
gurgling character. 

Auscultation of the Voice. 

In auscultating the voice, we must notice the intensity, the pitch, the 
quality, the distinctness and the thrill. 

i. The Laryngeal Voice. — This is heard over the larynx and trachea. 
The quality is laryngeal ; the intensity great ; the pitch high ; distinctness 
and thrill are well marked. 

2. The Pulmonary Voice. — This is heard over the lungs. Quality, pul- 
monary; intensity, feeble; pitch, low ; not at all distinct; there is but a 
moderate thrill ; the intensity and thrill are more marked in persons who 






The Life Insurance Examiner. 6t 

have a sonorous or vibrating voice. In the right infra-clavicular region, the 
intensity of the voice is usually greater, the pitch higher, and the thrill 
more marked than in the left. 

3. Increased Vocal Resonance. — This is heard over lung consolidated by 
pneumonia ; over cavities, over lung compressed by fluid, and over lung 
attached to the chest walls by old pleuritic adhesions, and sometimes in 
emphysema. The quality remains pulmonary ; the intensity is increased ; 
the pitch is higher, and the thrill is more marked. 

4. Diminished Vocal Resonance. — This is heard over small collections of 
fluid with obstruction of the bronchi ; over pleuritic adhesions, sometimes 
over consolidated lung ; and the intensity and thrill of the voice are 
diminished. 

5. Suppressed Vocal Resonance. — This occurs with large collections of 
fluid in the pleural cavities or thoracic tumors. 

6. Bronchophony is heard over consolidated or compressed lung, and 
over cavities. In quality it is bronchial ; the pitch is high; the intensity is 
variable ; the distinctness is marked, and the thrill varies. 

7. EgopJiony is a modified bronchophony, differing only in quality 
from it. It is heard over lung compressed by fluid just at the level of the 
fluid, and can only be heard well in persons who have a vibrating voice, 
and then even it is necessary to make them say some word which is of a 
vibratory character, such as "Brandt." 

8. Pectoriloquy. — This is heard over cavities and over solidified lung, 
and can often be best appreciated when the applicant whispers, during 
which the sound of the voice and the articulation of the word is transmitted 
from the chest. It is quite a hollow or cavernous voice. 

9. Amphoric Voice. — This is heard over large cavities and in hydro- 
pneumo-thorax. It is also found above the heart when the applicant 
whispers, and has a peculiar quality like that of amphoric breathing, while 
it resembles bronchophony. 

The Metallic Tinkle. — This is usually a sign of pneumo-thorax after 
perforation of the lung, but may be heard over large cavities, and, while 
heard in the voice and the breathing, consists of a series of tinkling 
sounds of a high pitch or metallic tone. 

EXAMINATION OF THE HEART. 

This is effected by inspection, palpation, percussion and auscultation, 
and we examine the heart in reference to its size, its impulse, its move- 
ments, its normal sounds and its abormal sounds. 

Location. — In the healthy chest the auricles are in a line with the 
third costal cartilages, the right auricle extending across the sternum, a 
little beyond its right border ; the left behind the pulmonary artery ; the 
right ventricle lying partly behind the sternum and partly to the left, its 



Z2 



inferior border being on a level with the sixth cartilage ; and the left ventricle 
mostly to the left of the sternum. As a whole, the heart extends vertically 
from the second space to the sixth costal cartilage, and in a trans 
direction from about half an inch to the right of the sternum to within half 
an inch of the left nipple. The left ventricle, a large portion of the apex 
of the right ventricle, and the greater portion of the left auricle lie to 
the left of the sternum. Behind the sternum lie the greater portion of 
the right ventricle and auricle, and a small portion of the left. To the 
right of the sternum lie the upper portion of the right ventricle and a 
portion of the right auricle. The whole of the anterior surface of the heart, 
except a triangular space corresponding to the lower portion of the right 
ventricle, is overlapped by the lungs. 

Relative Position of the V 

The mitral valve lies behind the cartilage of the fourth left rib, near the 
sternum. 

Tlie aortic valves lie behind the sternum, a little below the junction of 
the cartilages of the third ribs, and near its left edge. 

T/ie tricuspid valve Hes behind the middle of the sternum, on a line with 
the articulations of the cartilages of the fourth r: 

The pulmonary valves lie behind the junction of the sternum with the 
third left rib. 

INSPECT! 

By inspection we note the exact point of the heart's impulse where it 
strikes the walls of the chest, whether there is any change in the form of 
the cardiac region; or whether there is any unusual pulsation. In some 
healthy persons there is a slight protrusion over the seat of the heart, and 
this prominence is marked when the heart is hypertrophied, or when fluid 
has accumulated in the pericardium. In the perfectly normal chest, the 
two sides are very nearly symmetrical, but in disease the pra^cordial region 
may be either depressed or arched forward, and the intercostal spaces 
widened. The depression at the lower part of the precordial region may be 
natural, but if it is very marked, it is usually the result of pericardial inflam- 
mation. The most important feature in diagnosis furnished by inspection 
relates to the cardiac impulse. This is seen where the apex beats against 
the walls of the chest between the fifth and sixth ribs, about an inch inward 
from the nipple and an inch and a half downward. 

In lean persons this is very distinct, while in corpulent persons it is not 
at all perceptible usually. It is changed by different positions, and by dis- 
tention of the stomach after a full meal, by flatulence, and also in the 
act of expiration ; for during a long-drawn inspiration, the extended lung 
presses the heart inward and the impulse is discernible in the epigastrum. 
while during a forced expiration, the- beat moves upward and appears more 



The Life Insurance Examiner. 6$ 

extended and diffused. In disease the changes produced are many. The 
heart? is lifted upward and outward by the left lobe of an enlarged liver, and 
it is displaced by many effusions, notably the pericardial effusion. When 
the heart is enlarged, the impulse is visible lower down and over a larger 
surface. It may be crowded over to the right side and downwards by 
simple pleuritic effusion or emphysema, and in some cases of dilatation 
of the ventricles the underlying impulse will be visible. 

Palpation. 

The hand, when laid on the precordial region, can oftentimes feel im- 
pulses which cannot be seen. In many healthy persons the heart does not 
communicate any perceptible shock to the chest wall. The force of the 
impulse is temporarily increased by muscular exercise, by digestion and by 
sudden emotions, and also by any disease which depresses the vital forces. 
Fatty degeneration of the heart should diminish the force of the impulse, 
while dilatation of the ventricles, with hypertrophy, causes a heavy impulse 
over the whole precordial region, instead of causing the circumscribed apex 
beat as in the normal chest. The force of the impulse is also increased by 
morbid functional excitement, by acute pericarditis and endocarditis, and 
especially by hypertrophy of the heart. 

Besides the impulses, other phenomena may be studied by placing the 
hand over this region. The sounds of the heart may be analyzed by the 
different vibrations felt ; one is a long and dull, and the other a short and dis- 
tinct, vibration ; these are both due to the action of the valves. In valvular 
lesion, if the fingers are applied over the heart, at times a peculiar thrill or 
purring movement is perceived, called by Laennec the " purring tremor." 

Diminution of the impulse may depend upon feebleness of the action 
of the heart in consequence of the degeneration of its tissues, upon pros- 
tration of the whole system, or any condition which prevents the apex of 
the organ from impinging against the walls of the chest with its customary 
force, as happens in disease of the lungs and pericardium. 

Increase in the impulse is usually caused by hypertrophy of the walls of 
the left ventricle, and to a slight degree is also found in the early stage of 
endocarditis, of pericarditis, and in palpitation from functional disorders. 

The rhythm is, usually, in the normal heart perfectly regular, the heart 
contracting and dilating alternately in a perfectly regular way, the first and 
second sounds and the first and second silences following each other in 
regular sequence. In some healthy persons — and this must be remem- 
bered in connection with life insurance examinations — there is a regular 
intermission of the ventricular system, while in other persons the heart 
sounds are duplicated ; either the systolic or diastolic sounds, or both of 
them, may be doubled, and such reduplication is said to be due to a want 
of synchronism between the action of the two sides of the heart. The 



6 4 



The Life Insurance Examiner. 



heart's action becomes irregular in rhythm in valvular disease, in dilatation 
and hypertrophy of the ventricles, in fatty degeneration, in pericarditis, in 
thrombosis of the heart, and from nervous influences. 

Percussion. 

By percussion we determine the exact outline and size of the heart 
itself, and to do this perfectly the applicant should assume a recumbent 
position. Then, by a series of moderately strong taps, we proceed down- 
ward from near the middle of the clavicle until a dull sound, accompanied 
by decided resistance, tells us we are striking over the body of the 
organ, and this is usually at the lower border of the fourth cartilage, corre- 
sponding to the upper limit of the portion of the heart which is left uncov- 
ered by the lung. The superior border having been ascertained, we next 
percuss on the right side of the sternum on the level of the fifth rib, and 
across the bone, and over its left edge we find marked resistance and 
a duller sound, which marks that edge of the organ ; we then proceed 
across the cardiac region up to the point at which a clear, full pulmonary 
note demonstrates that the full lung tissue is reached. The apex of the 
organ is readily obtained by advancing in an oblique direction from the 
already ascertained right border ; but we can much more readily obtain 
this point by palpation. 

The range of dullness may be increased by hypertrophy of the 
ventricles or dilatation of the cavities, or when the pericardium contains 
fluid, and may be diminished at the close of a full inspiration, or in 
pulmonary emphysema — in the latter case by the production of a general 
distention of the air cells. The area of deep-seated dullness is increased 
by enlargement of the heart, whether due to hypertrophy or to ventricular 
dilatation, and is apparently increased by consolidation of the anterior 
border of the lung, and also by fluid in the left pleural cavity. 

Auscultation. 

The heart sounds should be first listened to while the person is breath- 
ing naturally, then while he is holding his breath, and finally during three 
or four forced inspirations. The examination should not be confined to the 
precordial region alone, but the whole thoracic cavity should be explored in 
order to locate the points at which the heart sounds are heard with the 
greatest intensity, and the examination should be proceeded with from be- 
low upwards, and from left to right. When the ear or stethoscope is applied 
to the healthy precordial region, two sounds of a very dissimilar character 
are detected. The first is long, dull, heavy and corresponds to the impulse 
against the walls of the chest ; the second is short and occurs after the 
impulse. These are followed by an interval of silence which does not inter- 
vene between the first and second, but between the second and first. 



The Life Insurance Examiner. 



These sounds are audible over the entire precordial region, but with unequal 
distinctness, the first being best heard over the lower portion of the heart, 
and the second at the base. The first sound is softer, lower in pitch, and 
more prolonged than the second, and coincides with the systole of the ven- 
tricles and the apex beat, and has its maximum of intensity in the fifth 
interspace, a little to the right of the left nipple. The second sound is 
higher pitched, sharper, shorter, and more superficial than the first, and is 
synchronous with the diastole of the ventricles, occurring after the pulsation 
of the arteries, and has its maximum of intensity at the junction of the 
third left rib with the sternum. The period of silence immediately following 
the second sound varies in length with the rapidity of the heart's action. 

The intensity of the heart sounds varies in health according to the 
force of its action, according to the conformation of the chest, and accord- 
ing to individual idiosyncrasies, being less in fleshy or muscular persons, 
with capacious chests, than in thin, narrow-chested, or nervous individuals. 

The extent of surface over which the heart sounds are heard varies, 
but there is for each sound a point of maximum intensity, where it is heard 
with greatest distinctness, and from which point it gradually fades until it is 
lost, or marked by other sounds. 

The sounds of the aorta are to be studied at the right edge of the ster- 
num at the second intercostal space. 

The mitral valve is listened to immediately above the beat of the apex ; 
while the sounds of the tricuspid, or right ventricle, are to be sought for in 
the vicinity of the ensiform cartilage. 

The modifications which the healthy sounds present when free from 
disease, in some cases resemble those due to morbid changes in the organ. 
They may be audible over a larger portion of the chest than usual, and 
they may be changed in character and rhythm. Their transmission over a 
larger space is unimportant, for, while they are undoubtedly more extended 
when the heart is enlarged, they are also more diffused when the sur- 
rounding tissues are condensed, and even in the most perfect health their 
range is very diversified. During a full inspiration, the sounds at the 
interspace between the second and third costal cartilages on the left 
side disappear almost entirely, and become faint at the aortic cartilage. 
In full expiration the first sound of the apex becomes much less dis- 
tinct, although the extent over which the heart sounds are heard is 
increased. Functional disturbances of the heart cause the sounds of 
the organ to increase in distinctness, and with strong nervous excitement it 
becomes short, sharp, and sometimes loud and ringing. When the walls of 
the heart are thinned, the sounds are permanently louder than in health, 
and shorter and more clearly defined when the walls of the heart are thick. 
The first sound is apt to be dull and prolonged ; if the structure of the 
heart be softened, the first sound is weakened ; hence this symptom should 
lead the Examiner to suspect fatty degeneration, or thickening of the 



ii The Lite Insurance Examiner. 

mitral and tricuspid valves, or a want of tonicity in the muscles of the 
organ. The second sound is not so liable to be changed as the first ; a 
thickening of the semi-lunar valves renders it somewhat duller ; or if they 
are abnormally thin, or in cases of great functional excitement of the heart, 
the sound is rendered more perceptible; this is especially notable in some 
cases of hypertrophy of the ventricles, and also takes place where a decided 
obstruction exists to the passage of blood through the lungs. In this case, 
this accentuated second sound is audible over the pulmonary artery alone. 
When the sounds are obscure, the Examiner should suspect the accu- 
mulation of fluid in the pericardium. In irregular action of the heart, which 
is apt to be associated with organic disease but may exist without it, the 
sounds are apt to be changed in the relative proportion to each other, and 
the pauses between them may be lengthened or shortened, or the sounds 
may intermit. 

Heart Murmtj 

Murmurs are sounds mainly produced either within the heart or on its 
surface, and the term has been applied to those adventitious sounds which 
pany or replace the normal sounds of the heart, and which are not 
heard in health. Their seat may be at the orifices of the ventricles, when 
they are called valvular or endocardial murmurs, or they may be within the 
heart, or they may be external and in the pericardium, when the 
termed exocardial or pericardial friction sounds. Those that are endo- 
cardial have a common quality in that they are all more or less blowing, 
although the sound is not alv :he same character or pitch, and they 

are not at all times the same in the same case, since the heart when excited 
:>und different from that which it does when beating quietly. 
This blowing sound originates from the altered relation of the blood to the 
part over which it moves. Most usually a cardiac murmur springs from a 
change at one of the orifices owing to the narrowing or roughening of the 
aperture, which interposes local obstruction to the flow of the blood ; or it 
may be due to insufficient closing of the valves. In the latter case, the 
blood regurgitates and the murmur is occasioned by the change in the 
circulation of the current of blood within the heart. 

There are two sources of error for which the Examiner should be on 
his guard. First, these blowing sounds are not infrequently present when 
the heart is violently excited, when both its valvular parts and muscular 
textures are healthy. Second, when altered blood causes the murmur. 

Murmurs correspond in the time of their occurrence to the contraction 
or dilatation of the heart, and, therefore, to the first or second sound ; at 
least, this, for the ore inaiy z nrposes of examination, is sufficiently accurate. 
It is often difficult, and sometimes impossible, to say whether a murmur is 
either systolic or diastolic ; the readiest method of determining this being 
to feel for the impulse with the fingers while listening to the murmur, the 



The Ltfe Insurance Examiner. 67 

blowing sound corresponding to the beat of the heart being systolic, and 
the % one between the beats of the heart, diastolic. A murmur once estab- 
lished is not always equally perceptible, sometimes becoming very faint, or 
disappearing entirely by the change in position on the part of the applicant; 
and sometimes is only manifest when the heart is acting forcibly. Posture 
exercises a very decided effect on murmurs. The blowing sound is distinct 
in a recumbent posture, becoming very faint, or disappearing entirely, when 
the applicant stands erect ; or the reverse is the case. 

A source of error is the resemblance between the natural respiratory 
sounds of the lungs and the blowing sounds of the heart, but a distinction 
may be readily made when the applicant suspends breathing. To determine 
the seat of a murmur, we must ascertain the point of its greatest intensity. 
The murmur produced at the mitral orifice is heard most distinctly at, or 
near the apex of the heart ; if generated in the right ventricle or at the tri- 
cuspid opening, it is heard immediately above the ensiform cartilage ; if 
developed at the origin of the aorta, it is heard most plainly at the sternum, 
somewhat toward its left border, on a level with the third intercostal space 
or the fourth rib, and with nearly equal distinctness over the second costal 
cartilage on the right side. The pulmonary artery is not often the seat of 
a murmur, but when it is, it is clearly perceptible in the second intercostal 
space on the right side, and extends to the junction of the third left cartil- 
age with the sternum. 

It is very important to examine each portion of the heart separately, 
since the sounds of valvular disease may coexist in the greater portion of 
the heart, but the greater intensity of the sounds of one portion of the 
valves may obscure the location of the others. When satisfied as to the 
seat of a murmur, we naturally turn to inquire into its origin, and there is 
nothing in the murmur itself which will tell us positively whether it is 
caused by an alteration of the fluids or connected with any appreciable 
change in the structure of the heart. As a rule, a harsh murmur results from 
organic disease, and a soft murmur from functional disease, but there are 
many exceptions, and we can judge with more certainty from the time of the 
blowing sound. A murmur attending distention of the heart indicates in- 
jury of the orifices ; while a murmur occurring during the contraction may 
indicate simply a change in the state of the blood and in the force and 
velocity with which it is circulating ; but. in the latter case, the abnormal 
sound is temporary and disappears with the excitement. When arising 
from an impoverished state of the blood, it is generally soft, of low pitch, 
accompanied with a humming sound in the veins of the neck, and is present 
over the base of the heart. 

It is a great mistake to suppose that every murmur heard over arteries 
is connected with disease of the heart, as it is frequently from impoverished 
blood, and it is even stated that pressure of a healthy heart may generate 
a murmur. To describe more in detail the murmurs of the interior of the 



63 



The Life Insurance Examiner. 



heart, the elements of quality and intensity hold a subordinate place, for 
the same murmur at different times may be grating, rubbing, blowing or 
muscular in character, without its significance being altered by any of 
these changes in quality. 

The precise pathological significance of endocardial murmurs is appar- 
ent from the following table, taken from Loomis : 



Table of Cardiac Murmurs. 



Periods of Heart's 
Action. 



Seat of Murmur. 



Systolic. 



Diastolic 



Left side 
of heart. 



Right side 
of heart. 



Left side 
of heart 



Right side 
of heart. 



Aortic. 

Mitral. 
Pulmonary. 

k Tricuspid. 
Aortic. 

, Mitral. 

f Pulmonary. 



Cause of Murmur. 

Obstruction to the onward flow of blood 
through the aortic orifice, or through the 
aorta. 

I Regurgitation of blood through the mitral 
[ valve into the left auricle. 

Obstruction to the onward flow of blood 
through pulmonary orifice, or through 
pulmonary artery. 

Regurgitation of blood through the tricus- 
pid orifice into right auricle. 

f Regurgitation of blood through the aortic 
orifice into left ventricle. 

] 

| Obstruction to the flow of blood from left 
[ auricle to left ventricle. 

r Regurgitation of blood through the pul- 
monary orifice into right ventricle. 

Obstruction to flow of blood from right 
[ auricle into right ventricle. 



Tricuspid. 

The sounds which originate on the outside of the heart, or pericardial 
murmurs, result from irregularities of the surfaces of the pericardium ; the 
smooth, serous covering of the heart, while roughened by deposit of any 
kind, gives rise during movement to a sound which may be single, but is 
more usually double, and in character is very variable ; it may be a distinct 
to and fro rubbing murmur, or may be scratching, grating or whistling, but 
has one quality which is constant and diagnostic, although it is often 
difficult in spite of this to distinguish the friction. The sound, too, is apt 
to mask the sounds of the heart, and it is not at all times, although heard 
over the cardiac region, due to inflammation of the pericardium, for the 
exudation maybe on the surface of the pleura adjacent to the pericardium, 
and the murmur be caused solely by the movements of the heart ; and, 
again, the sound heard in the pericardial region is in reality the rubbing of 
an inflamed pleura ; but in this case, if the person suspends breathing, the 
pleural sounds cease. There are also some sounds produced by the action 
of the heart, which are neither cardial nor pericardial ; these sounds are 
mostly systolic and inspiratory, and usually cease with cessation of the 
respiratory movements. 



EXAMINATION OF THE PULSE. 



THE PULSE. 

riHHE pulse, when felt by the tips of the fingers at the wrist, or elsewhere, 
registers the change in the fullness or distention of the artery, as the 
-JL blood is forced through the systemic circulation by the contraction 
of the heart. The best way to measure this fullness, or tension of the pulse, 
is to compress the artery with the index finger, while the two adjoining 
finger tips placed more distant from the heart, register the amount of pres- 
sure necessary to stop the flow of blood. 

The Sphygmograph is an instrument which registers the various 
qualities of the pulse by means of tracings on a diagram. From an analysis 
of these we perceive, that what may appear simple to the sense of touch, 
is really a complicated phenomenon, requiring careful study. 

Pulse Tracings. — The sphygmograph demonstrates that the move- 
ment of the artery is a compound of three waves, called the summit wave, 
the tidal wave and the dicrotism. 

The summit wave, which caps the line of ascent of the trace, is due 
to the sudden vibration in the blood column, immediately following the 
lifting of the aortic valves by the discharge of blood from the left ventricle. 

The tidal, impletion, or small secondary wave, is due to the distention 
of the arteries, following the increased pressure in the aorta and great 
arteries from the sudden influx of the ventricular contents. 

The dicrotism, or great secondary wave, is an oscillation of the current 
of blood in the arteries, mainly produced by the recoil of the blood column 
from the quick closure of the aortic valves. 

Typical Pulse Tracing.— (See fig. i.) A pulse trace consists in a 
line of ascent, a to b, ending in the summit wave b, and corresponding with 
the first part of the ventricular systole. From the summit wave the line 
falls until it is again raised by the tidal wave, due to the impletion of the 
vessel. After the tidal wave, a more marked descent occurs, called the 
aortic notch e, and the line again raises into the dicrotic wave d. 

The line of descent from b to a is then broken by two waves and two 
notches. The two waves have been described ; of the two notches, one 
precedes the tidal wave and indicates a slight collapse in the arterial wall 
after the oscillation, called the summit wave; while the other, called the 



The Life Insurance Examiner. 



aortic notch, precedes the dicrotic wave, and marks the fall in pressure on 
the arteries antecedent to the closure of the aortic valves. 



b 

\ d 

e \ 

x V 

a a 



Fig. i. — Typical pulse trace: a to 3, line of ascent; b to a', line of descent; 3, summit 
wave ; c, tidal wave ; <V, dicrotic wave, or dicrotism ; e, aortic notch. 



The instant the aortic valves close, the line is interrupted again. It 
is the bottom of this aortic notch, marking the closure of the aortic valves, 
which indicates the end of the ventricular systole. The rest of the line of 
descent corresponds with the diastole of the ventricle. 

Modified Pulse Tracings. — The pulse trace is modified by the state 
of arterial fullness, or tension. 

High tension is denoted thus — The line of ascent is less lofty ; the tidal 
wave is large and often blended with the summit wave ; the aortic notch is 
shallow ; the dicrotism not much developed, and the line of descent is 
more gradual. 

Low tension. — The line of ascent is lofty ; the summit wave distinct ; 
tidal wave small ; the aortic notch deep ; the dicrotism highly developed, 
and the line of descent sudden. 

In arterial degenerations, when the normal elasticity of the arteries 
is lost, these modifications are interfered with. 

The rate, rhythm and force of the pulse depend upon the heart. 

The art of feeling the pulse consists in discovering, through the sensa- 
tion of feeling, the condition of the heart, arteries and blood. 

A hard, cord-like artery indicates degeneration or senile changes. 

Frequency OF THE Pulse depends on the rate of the cardiac con- 
tractions. This rate varies with age, position of the body, sex, stature and 
other physical or psychical influences. In the newly born infant the pulse 
beats from 130 to 140 per minute, but the rate gradually falls, until after the 
sixth year it is under 100. Up to the age of maturity, there is a further 
decrease of thirty beats to about seventy per minute. In old age the rate 
often rises slightly. 



The Life Insurance Examiner. 



7i 



Postures. — The pulse is slowest in the recumbent position ; sitting, it is 
five beats Faster ; and standing, it is ten beats faster in the male and seven 
in trie female. 

Sex. — The female of seven years has about ten pulse-beats a minute 
more than a male of the same age. 

Stature. — Persons six feet in height have a pulse three or four beats 
slower than men five and one-half feet high. 

Normal Pulse-beats per Minute. 



f Males. 


Females. 


Youth 

Adult 


80 to 90 
70 to 80 
60 to 80 
75 to 85 


80 to 95 
75 to 85 
60 to 85 
75 to 90 


Middle life 

Advanced life 





Increased frequency in health is occasioned by any kind of exercise; 
mental emotion or nervous excitement ; a full meal ; it is higher in the 
evening than in the morning ; when awake than asleep. In disease a quick 
pulse may be one of its first indications, as in fevers, debility, chronic valvu- 
lar affections of the heart, nervous disorders, intemperance, etc. 

The jerky pulse is a hurried beat followed by an abrupt stop, and indi- 
cates defect in the aortic valves, or some nervous affection. The water- 
hammer pulse denotes aortic regurgitation. 

Diminished frequency of pulse rate is not common. It is seen in some 
of the blood diseases, jaundice, anaemia, diabetes, convalescence from pneu- 
monia, in relapsing fever, fatty degeneration of the heart, in some nervous 
affections, especially of the medulla oblongata, wherein it has fallen to about 
twenty beats per minute ; in tumors pressing on the aorta or arteries; in 
diseases of a depressing nature. 

Rhythm of the Pulse. — Depends on the action of the heart. Varia- 
tions are of two kinds, intermittence and irregularity. 

The Intermittent Pulse means the omission of a beat occasionally. 
Intermittences may occur regularly, say every twentieth beat, or irregularly, 
and are met with more frequently among the old than the young, in some 
cases being unassociated with organic diseases. 

Causes. — It may be caused, temporarily, by nervous excitement ; in 
other cases, by hypochondriasis, dyspepsia, excessive use of tobacco or 
narcotics and stimulants, gout, over-work, fatty degeneration of the heart, 
or some cardiac neuroses. It may be the first symptom of oncoming 
malignant disease. In some persons, especially the old, it is habitual, 
though they are otherwise healthy. 

The Irregular Pulse presents itself in two forms — irregularity in 
frequency and irregularity in force, or inequality. The two are frequently 



7- 



The Life Insi Examii 



associated, no two pulsations being equal in force, or succeeding each other 
at equal intervals. In other cases a number of steady beats, regular in 
frequency and force, may be followed by a disorderly series, unequal and 
irregular. 

Diseases of the mitral valve and cardiac dilatation usually exhibit these 
abnormalities, although they are incident to any form of heart disease. 

Mitral insufficiency affords common examples of unequal and irregular 
pulse, though the beats may be only slightly unequal in size and form, but 
perfectly regular in the periodicity of their occurrence. 

In mitral stenosis, irregularity and intermissions are usually associated 
with inequality. Intermissions are called false when the ventricular systole 
is too weak to make them apparent at the wrist. 

Exercise increases these abnormalities of pulse in mitral diseases. 

Inequality in the size of pulsations often depends on respiratory 
influences. Deep inspiration reduces arterial tension, lessens the size of 
and quickens the pulse. Extreme expiration raises the tension, increases 
the size of and slows the pulse. 

The suppressed pulse sometimes occurs in one or all of the arteries. 
When general, it is due to cardiac weakness ; when partial, to either com- 
pression, thrombosis or aneurism of the main artery. 

The retarded pulse is where the pulsation occurs later in one artery 
than in another, and usually indicates aneurism. 

THE FORCE OF THE PULSE is the product of the heart's vigor, and is 
estimated by the finger by the amount of force required to obliterate it ; 
and by the sphygmograph by the pressure required to develop a typical 
tracing. 

The state of the smaller blood vessels regulates the distribution of this 
cardiac force. 

A soft, compressible pulse results from the small amount of blood re- 
tained in the artery when it is relaxed, and a vigorous heart quickly distrib- 
utes its I 5f the whole vascular area. 

A hard and incompressible pulse results from fullness of the artery 
with blood under high pressure, when the arterioles are contracted and the 
heart's force is retained in the arteries. 

The force of the pulse is thus modified by the state of the peripheral 
circulation ; the vascular tension being in inverse proportion to the fre- 
quency and suddenness of the heart's action. 

OTHER VARIETIES : F PULSE. — The ; :ze of the pulse is determined by 
the volume of blood expelled by the ventricle and the fullness of the 
arteries. A hard and wiry pulse accompanies contracted arteries : a large 
and soft pulse occurs when their walls are relaxed. 

The flickering pulse indicates feeble and unequal contractions of the 
ventricles. An unduiatory, weak pulse is due to the influence of respira- 
tion, which varies the tension. 



The Life Insurance Examiner. 73 

The sudden pulse is shown on the tracing of the sphygmograph by a 
nearly vertical line of ascent, resulting from quick ventricular systole. 

The gradual pulse has an oblique line of ascent, and results from slow 
ventricular systole. 

Varieties of Hard Pulse. — (1 ) The hard, frequent, sudden and small 
pulse, found in peritonitis, enteritis and pericarditis. (2.) The hard, slow, 
gradual and large pulse of contracted kidney. (3.) The hard, large, often 
gradual pulse of cardiac hypertrophy and degeneration of blood vessels. 
(4.) The hard, sudden, jerky, large and vibratory pulse of aortic insufficiency, 
with strong ventricle. 

Varieties of Soft Pulse. — (1.) The soft, frequent pulse of pyrexia; 
dicrotous and hyper-dicrotous pulses. (2.) The soft, frequent and large 
pulse of rheumatic fever. (3.) The soft, small, frequent and sudden pulse 
of debility. (4.) The soft, frequent and small (running) pulse of collapse in 
fever. 

Anomalies of Pulse are sometimes due to irregular distribution of 
the arteries. The radial artery may lie deep, or be so small as not to be 
felt readily. In those cases other arteries must be tested to show any of 
the foregoing qualities of pulse. 

Remarks. — At the present stage of scientific research, the pulse indi- 
cates the condition of the nervous, as well as the circulatory system, and 
the subject should be mastered by the Medical Examiner. Unless absolute 
disease is the cause, many abnormalities of pulse are individual idiosyncra- 
sies, and need not debar from insurance ; but all such cases should be stated 
plainly in the application. The pulse rate, when below sixty or above 
ninety per minute in the adult, deserves critical analysis, and, at least, post- 
ponement of judgment. 

EXAMINATION OF THE ABDOMEN. 

The physical exploration of the abdomen does not yield such perfect 
results as when this method of diagnosis is applied effectually to the thorax, 
but still the knowledge thus gained is often most valuable. 

The Metho'ds of Physical Diagnosis. 

INSPECTION. — By inspection we learn the shape, size, form and move- 
ments, and to inspect the abdomen satisfactorily, the applicant may be 
either standing or sitting ; as a rule, a recumbent posture being less eligible. 

It is necessary to remember that even in health the appearance of the 
abdominal walls is modified by certain physiological conditions. It is more 
voluminous in females — especially such as have given birth to several chil- 
dren — than in males. It increases in size in advancing years, particularly 
when the applicant exhibits a tendency to obesity, and the upper portion 
is more distended after a copious meal than when the stomach is in an 



74 The Life Insurance Examine r. 

empty state. In diseased conditions, we may have either a partial or general 
enlargement of the abdomen. The latter may be caused by accumulations 
of air in the intestines, or by fluids or tumors in the peritoneal cavity, while 
a partial enlargement may be produced by an increase in the size of the liver 
or spleen, or by induration or swelling of the mesenteric glands, or by solid 
tumors or hernia, or by abnormal conditions above the diaphragm. A 
pleuritic or pericardial effusion, or even emphysema of the lungs, may give 
rise to a marked fullness below the margin of the ribs. 

Retraction of the abdominal parietes is observed in general emaciation, 
especially when dependent upon chronic diarrhcea or dysentery, or upon a 
narrowing of the cardiac orifice of the stomach. It may be also noticed in 
lead colic and syphilitic diseases. When the superficial veins are distended, 
we suspect an obstruction to the flow of blood in the large veins of the 
abdomen, either in the portal system or the vena cava. When the depres- 
sion of the umbilicus is diminished, it is usually a sign indicative of general 
abdominal enlargement. Movements of the abdomen during inspiration 
may be of different kinds. When a tumor or any other impediment inter- 
feres with the free action of the diaphragm, the act of breathing gives rise 
to a motion which is very slight. This movement is much exaggerated by 
diseases within the thorax. The rolling of the intestines is sometimes 
visible externally, and also the spasmodic contraction and relaxation of the 
abdominal muscles, together with the shiftings of the accumulations of gas, 
which give rise to a series of jerking elevations. A pulsation mainly in the 
epigastric region is sometimes observed, which is not infrequently mistaken 
for aneurism. 

MENSURATION is mainly useful in determining the exact increase or 
decrease of abdominal dropsies, visceral enlargements, tumors and corpulency. 

PALPATION. — By this method of examination we can judge of the size, 
position and consistence of the viscera, which are felt through the abdom- 
inal walls, and can determine whether the parts are firmly attached or 
movable, and whether or not they possess an independent motion ; we can 
also ascertain whether they are tender or not, and can detect the peculiar 
feeling of fluctuation attending the presence of fluid in the abdominal 
cavity. We can also by the sense of touch determine the state of the 
parietes, whether hot or cold, resistant or elastic or cedematous. 

When palpation is practiced, the abdominal muscles should be relaxed. 
In order to do this effectually, the applicant should be placed on the back 
and the thighs flexed on the body, although this position may be varied by 
turning him from side to side or examining him erectly. The character and 
intensity of the pain which the pressure calls forth is a diagnostic sign of 
considerable value. If deep pressure produces pain, we may usually consider 
that the disease is deeply seated, while neuralgic or nervous pain, such as 
that of colic, may be relieved rather than increased by pressure. These 
symptoms are rarely met with in applicants for life insurance, as they are 



The Life Insurance Examiner. 75 

usually in a state of health ; it is not usual to have an applicant appear for 
examination in acute stages of abdominal disease, to which these rules 
would apply. 

By palpation we determine the size and position of the viscera, the 
existence of swellings and tumors, whether deep or superficial, small or 
large, hard or soft, elongated or smooth, and whether or not they possess 
independent motion. 

PERCUSSION. — Percussion is perhaps even more valuable as a means of 
diagnosis than palpation, for by it we can map out the different organs with 
accuracy, judging of the position of the stomach and the intestines, fixing 
the boundaries of the distended bladder and the borders of the liver and 
spleen. We can also tell whether a distention of the abdomen is produced 
by a solid tumor, a liquid, or by air. The applicant should be placed in 
the same position as for palpation. 

The liver is one of the most important organs to examine; its upper 
boundary is determined by percussing with moderate force in a line from 
somewhat above the right nipple to the lower part of the thorax, until 
marked dullness and resistance demonstrate that a solid organ has been 
reached; this corresponds to the upper border of the liver; anteriorly, it 
extends from the lower extremity of the sternum to between the fifth and 
sixth ribs. At the side it is generally found in the seventh intercostal space, 
while near the vertebral column it is ordinarily on a level with the tenth, 
eleventh or the ninth interspace. The dullness of the left lobe reaches 
nearly two inches across the median line, but it is difficult to distinguish 
the flat sound of the liver from the flat sound of the heart, lying so 
near it. 

The inferior margin of the liver is determined by percussing downward 
from the already ascertained line of dullness until the distinct tympanitic 
sound of the large intestine is elicited. 

Anteriorly, the inferior border of the liver will usually be found to be 
immediately on or to project below the last rib. Posteriorly, this border can- 
not be determined positively, for it becomes continuous in the dullness 
occasioned by the presence of the right kidney ; but the lower margin of 
the left lobe is usually met with at the upper part of the line drawn from 
the umbilicus to the ensiform cartilage, although a much distended bladder 
may cause a strictly defined dullness lower than the dullness of the sur- 
rounding liver. 

The percussion sound elicited over a healthy abdomen may be tym- 
panitic, dull, or flat. Over the central portion of the liver, kidneys and 
spleen, the percussion sound is flat, while over that portion in which the 
intestine or stomach is overlapped by them, it is dull, with a tympanitic 
quality ; over the stomach and intestines it is tympanitic ; if a fluid occu- 
pies the abdominal cavity, the percussion sound will be flat. The percus- 
sion flatness is unnatural and increased over a distended bladder or uterus, 



jo The Life Insurance Examiner. 

an enlarged spleen, kidney, mesenteric gland or liver, and over ovarian, 
aneurismal and other tumors, while an increased area of tympanitic reson- 
ance is found in gaseous distention of the stomach and intestines. 

The spleen is not as easily mapped out as the liver, for if the stomach 
contains much fluid, or if the intestines be distended with gas, it is very 
difficult to determine the dull sound of the spleen. To map out this organ, 
the applicant should be placed on the right side with his legs flexed, or he 
should stand erect, and the percussion should be practiced with consider- 
able force in a line from the axilla to the crest of the ilium. Its upper 
boundary is usually to be found at the ninth or sometimes at the tenth rib, 
and its lower at or about the twelfth rib ; its lateral borders are usually 
determined by percussing from the median line to a point between the 
lines which mark the superior and inferior margins; but posteriori}-, we 
cannot define the border of the spleen accurately, because its dullness be- 
comes continuous with that of the left kidney. The average size of the 
spleen is four inches in length and three in width, but it is increased ma- 
terial}' in a diseased state, and this should be noted in applicants who have 
suffered from malaria to any marked degree. 

The kidneys cannot be mapped out with any degree of accuracy by 
percussion except as to their inferior or outer borders, so it is useless to 
consider that question here. 

The stomach, when not distended unusually with gas or food, renders a 
sound which is ringing, hollow or tympanitic to a certain degree, although 
not to the same extent as the intestine. To determine its boundaries it is 
necessary, first to mark out the lower margin of the liver, then the heart 
and the inner border of the spleen. 

The cardiac extremity of the stomach is situated near the left of the 
apex of the heart, about opposite the seventh rib; its lower border is ascer- 
tained by percussing in a downward direction till the colon is reached. 
The colon itself yields on percussion a sound of a more tympanitic charac- 
ter than the stomach, and the sound may be said to be rather amphoric 
than tympanitic. The small intestines, unless filled with solids or fluids, 
or distended with gas, render a sound of higher pitch and smaller volume 
than the colon, and by this deep-toned sound their position may be accu- 
rately determined. 

AUSCULTATION. — This is often interfered with, and its results rendered 
uncertain, by changes occurring in the abdominal walls. If a layer of fat 
exists, as in some cases of obesity, auscultation would be very unsatisfac- 
tory, and also in an cedematous condition, as in Bright's disease ; in this, 
the surface of the abdomen usually presents a smooth, shining, white 
appearance. The abdominal muscles are also sometimes abnormally de- 
veloped, thereby interfering with examination; but auscultation is occasion- 
ally serviceable in aiding in the detection of abdominal aneurism, or we may 
hear a friction sound from the presence of a roughened peritoneum, or an 



The Life Insurance Examiner. jy 

enlarged spleen may give rise to a distended, blowing murmur ; but, as a 
rule,Jt is a diagnostic procedure that is rarely necessary or of value. 

EXAMINATION OF THE URINE. 

The examination of urine is of great service in the diagnosis of diseased 
conditions, and is accomplished by chemical and microscopical means. 

Chemical Examination. 

The specimen to be examined should be collected in a perfectly clean 
receptacle ; should be passed in the presence of the Examiner, and examined 
with reference to, 1st, its general appearance and color; 2d, its odor; 3d, 
the quantity passed in twenty-four hours ; 4th, the reaction ; 5th, its specific 
gravity ; 6th, the presence or absence of albumin ; 7th, the presence or 
absence of sugar ; 8th, the microscopical appearances. 

General Appearance and Color. — This varies considerably even in 
health, and is much affected by food and medicine, and also by various mor- 
bid processes. If of a smoky or red aspect, it should lead us to suspect 
the admixture of blood ; or if highly colored, uric acid ; a very light color 
usually denotes an increase of water, as in diabetes, hysteria or nervous 
affections; or if green, yellow or brown, bile should be suspected, although 
very much the same tint is imparted to the urine if the applicant has 
been taking rhubarb. The color is deepened if the applicant has been 
drinking strong coffee ; a violet color is imparted to it if the applicant has 
been taking turpentine ; and a yellow color from taking senna ; while disin- 
tegrated blood renders it black. In health, the color usually varies from a 
pale straw to a brownish yellow. Highly colored urine usually indicates 
the existence of some pathological condition, and generally leads us to sus- 
pect organic disease of the liver, or some inflammatory disease, if not due to 
an excess of uric acid or urates. The presence of bile, which is indicated 
by a dark olive tint in the urine, may be rendered certain by a small quan- 
tity of nitric acid, for as soon as the two fluids are brought in contact, the 
drop of acid will be fringed with a beautiful display of colors, green, violet 
and red, which will rapidly disappear. 

Odor. — Normal urine, immediately after being voided, possesses a 
sweetish, aromatic odor, but many kinds of food and drink transmit to it 
their characteristics, as, for instance, asparagus, which is recognized by 
everyone. Bright's disease, jaundice, diabetes, and certain affections of the 
bladder, change the odor of the urine, each having its distinctive character. 

Quantity Passed in Twenty-four Hours. — This in healthy persons 
varies greatly, the mean daily discharge ranging between forty and fifty 
ounces, this variation depending greatly on the quantity of fluid taken into 
the system and whether the skin and bowels are normal in their action. To 
determine the quantity accurately, the urine should be carefully measured in 



78 The Life Insurance Examiner. 

a graduated glass. When unusually scanty, if the applicant has not abstained 
from liquids above his habit, and if the water has not been eliminated in 
excess by some other channel, as by the skin or bowels, we must suspect 
cirrhosis of the liver, some forms of Bright's disease, or some condition of 
the heart which, directly or indirectly, causes passive congestion of the renal 
veins, whereby the renal circulation is impeded. If the flow of urine is un- 
usually abundant, and not caused by the cooling of the surface of the body, 
or by the taking of large quantities of fluid into the system, it is usually in- 
dicative of one of two maladies, diabetes or atrophic degeneration of the 
kidneys, although a temporary excess of urine occurs in hysterical parox- 
ysms, and other convulsive attacks in both males and females. An in- 
creased tension in the arterial system, such as is frequently found in hyper- 
trophy of the left ventricle, is also very frequently the cause of increased 
secretion of urine. 

REACTION. — The reaction of urine is usually ascertained by means of 
litmus paper. If acid, it reddens blue litmus paper, and if alkaline, it ren- 
ders red litmus paper blue. 

Healthy urine is usually highly acid when first passed, but, after stand- 
ing for a certain time, all urine becomes alkaline. The urine is abnormally 
acid in febrile and inflammatory affections, especially of the heart, lungs 
and liver, and is usually strongly alkaline in some diseases of the genito- 
urinary organs, and in affections of the brain and spinal cord. The degree 
of acidity, even in health, is not always equal, and is much influenced by 
digestion. If no food has been taken for hours, the discharge is highly acid, 
while that passed just after a meal, during the process of digestion, is but 
faintly so, and may be neutral, or even alkaline. 

SPECIFIC GRAVITY.* — Specific gravity of healthy urine ranges between 
1.012 and 1.030, the average being about 1.020; it is highest soon after eat- 
ing, and lowest after large quantities of fluid have been taken. 

The most convenient method for estimating the specific gravity is by 
means of the urinometer, an instrument consisting of a blown glass float, 
terminating inferiorly in a small bulb containing mercury, and superiorly in 
a stem which is graduated. The average specific gravity of urine is increased 
or diminished in disease. It is highest in diabetes and lowest in hysteria. 



* Medical Examiners in their report to the home office should be careful to designate the kind 
of urinometer employed, as instruments differ greatly. For instance, the ordinary English urinometer 
is divided into degrees running from 1000 to 1060, while there is a German (Newbaun & Vogel) uri- 
nometer graduated from 1000 to 1040, and still another (Heller's) running from 1000 to about 
1007. It will be noticeable that there is a great difference in this regard. Thus one degree 
of Heller's urinometer corresponds to seven degrees of the English ; therefore, if we have a specific 
gravity of the urine of 1003 Heller, we may translate the same into the English standard by stating 
that the urine has a specific gravity of 1.021. Or, if it is 1004 Heller, we have 1.02S English. In 
this latter case an examination for sugar should be made, while in the former no such examination is 
required. 



The Life Insurance Examiner. 79 



When abnormally low, some exhausting non-inflammatory complaint, such 
as Brlght's disease, is to be suspected unless large quantities of fluid, such as 
water or beer, have been recently taken. In such cases, postpone the appli- 
cant until a more favorable specimen of urine can be passed. The Examiner 
should not accept an applicant whose urine is below i.oioin specific gravity 
at the time of the examination, and all urine of persistent low specific 
oravit}' should be carefully examined chemically and microscopically. 

Albumen. 

ALBUMINURIA is the diseased condition of the system indicated by the 
presence of albumen in the urine. Albuminous matters are found in the 
urine of those suffering from spermatorrhoea, pyuria, hematuria, hsematin- 
uria, etc. Albuminuria, especially of the temporary type, may occur inde- 
pendently of organic diseases of the kidneys or any other organ, although it 
always exists in Bright's disease at some stage. It sometimes exists without 
objective symptoms ; but, as a rule, the chronic form is accompanied by a 
pasty complexion and dry skin, with oedema of the eyelids and cellular 
tissue of the lower extremities ; digestive troubles, such as nausea, flatu- 
lence and constipation ; nervous disorders, with headache, lassitude and 
muscular weakness ; frequent micturition at night and palpitation of the 
heart. It often follows congestion of the kidneys in inflammatory diseases, 
such as measles, scarlet fever, smallpox, typhoid and malarial fevers, pneu- 
monia, diphtheria, rheumatism, peritonitis, etc. It is found in emphy- 
sema, cirrhosis of the liver, organic heart disease, pregnancy, and abdominal 
tumors when the circulation of the blood is obstructed, and an impoverished 
state of the blood, such as exists in anaemia, pyaemia and scurvy, often gives 
rise to it. 

HEAT AND Nitric Acid TEST. — (See Part I., Urine Examination, for 
another test.) This test is sufficiently accurate for the purposes of life insur- 
ance if it is properly done. Take a drachm or two of fresh urine ; if cloudy, 
filter through clean sand or filter-paper; boil first and then add a drop of 
dilute acid to make sure that the reaction is acid ; for heat does not precip- 
itate albumen in alkaline urine, and too much acid will cause the same 
result, because, in the first instance, heat may form alkali albumen, and in 
the second acid albumen, both of which are soluble in the urine. If the 
urine remains cloudy after this test, albumen is present, and the addition 
of an excess of acid will not dissolve it. 

The precipitate caused by excess of urates will disappear by boiling, 
and that caused by phosphates is dissolved by the nitric acid. 

The Nitric Acid, or Heller's Test, has been adopted by the 
Clinical Society of London, as the most reliable and delicate. The Medical 
Record of New York, in its issue of April 50, 1887, published a most interest- 
ing paper on the tests for albumen, by Dr. H. B. Millard, which was read 
and discussed before the New York Academy of Medicine. Put a drachm 



8o The Life Insurance Examiner. 

of pure, colorless nitric acid in a clean test-tube measuring three-quarters of 
an inch in diameter. Incline the test-tube at an angle of forty-five degrees, 
and allow an equal quantity of filtered urine to slowly trickle down upon 
the acid from the pipette. The urine must overlie the acid. If albumen 
be present, it is quickly coagulated by contact with the acid and a white, 
lardaceous layer, varying in thickness according to the quantity of albumen, 
is formed at the line of junction. When the quantity of albumen is small, 
it may be necessary to allow the tube to stand a quarter or half an hour 
before the white zone is distinguishable. If the urine be allowed to cool, 
four distinct zones : first the lower one, orange colored ; next the albumin- 
ous layer ; then the urates, and the upper one, composed of mucin, can be 
distinguished. 

THE NITRIC MaGNESIAN Test is a modification, by Dr. Sir William 
Roberts, of the pure nitric acid test, and is described in an article by him, 
published in the Medical Chronicle, of London, October, 1884. It is pre- 
pared by mixing one part of pure nitric acid with five parts of a saturated 
solution of the sulphate of magnesia, and filtering. It is used the same as 
the former test, and is recommended as a very delicate one. It is one-third 
more delicate than the pure nitric acid test, showing one part in 150,000, 
where the latter shows one in 100,000. It also condenses the layer of 
albumen, so that an estimate of the percentage of albumen present can be 
more readily made. 

Remarks. — The other tests for albumen can be found in any medical 
text-book; but the first one mentioned is sufficiently accurate, since it indi- 
cates one part in 100,000. When the urine- contains sugar as well as albu- 

* Urine Examination" IN Life Insurance is the title of an article published in the St. Louis 
Medical and Surgical Journal for April, 1887, from the pen of Dr. \Ym. J. Lewis, Consulting 
Surgeon of the Travelers Insurance Company of Hartford Conn. He concludes that the value of 
such examinations, from a financial 'the company's) standpoint, as well as a scientific point of view, 
appears to be limited. Dr Lewis concludes: "From the large expense attendant upon such 
examinations ; the impossibility of obtaining a correct analysis in the majority of cases ; the small 
percentage of deaths from genito-urinary diseases, even when no such examination has been 
required ; and the objection on the part of the applicant to submit to the ordeal, insurance com- 
panies might infer that they have little to gain and much to lose by making it a prerequisite for 
insurance in all cases. On the other hand, when large amounts are involved, or when some symp- 
tom is present to indicate a suspicion of abnormal urine, extra precaution, by requiring an analysis, 
becomes necessary." 

Nevertheless, we venture to say. that the number of companies and Medical Examiners willing 
to forego a urinary examination, is growing less and less every year, because it is so valuable as a 
corroborative test of. the value of coexisting symptoms of albuminuria, diabetes, etc. Few Exam- 
iners would care to predicate the existence of albuminuria and diabetes., when the urinary analysis 
reveals the absence of albumen and sugar ; and vice versa, when the proper tests demonstrate the 
presence of these abnormal ingredients, where is the medical officer who would make it his habit to 
recommend such cases to his company for insurance, even though there were no other signs of either 
of those diseases ? As these urinary tests become more generally required and more accurately per- 
formed, it seems probable that the mortality of the insured from diseases of the genito-urinary 
organs will be still further reduced. 



The Life Insurance Examiner. 8i 



min, it must first be boiled to precipitate the albumin, then filtered to sepa- 
rate it, after which the test for sugar may be made. 

It is well to remember that sugar or albumin, when discovered in the 
urine, are not necessarily indicative of fatal diseases, such as diabetes or 
Bright's disease. 

They may be the results, simply, of some functional disturbance. 

Cases in which these conditions are found should be postponed for 
further and repeated examinations. But if constantly present, the appli- 
cant should be rejected. 

In either case it would be well to supplement the chemical by a 
microscopical examination, so as to remove all elements of doubt as nearly 
as possible. 

In the early period of life insurance it was not customary to examine 
the urine, except when the physical signs pointed to the existence of 
Bright's disease or diabetes. Afterwards it became the custom to examine 
it when the amount of insurance applied for reached a certain limit. At 
the present time the condition of the urine is investigated in almost all 
cases, irrespective of the amount of insurance applied for, and the micro- 
scope is also often called into requisition. It is neither fair nor reasonable 
to reject an applicant, and, as it were, to pass sentence of death upon him, 
merely because one test-tube examination has shown that the urine contains 
a certain amount of albumin. The albuminuria may be simply functional, 
or it may be what is called cyclic, and in neither case be a symptom of 
Bright's disease. On the other hand, it is a well-known fact that chronic 
renal disease may exist while the urine, as far as the results of a mere test- 
tube examination go, gives no indication of its existence. The corrective 
of the test-tube examination, is the microscopical investigation. If tube- 
casts and other microscopical evidences of chronic nephritis be found, then 
the suspicion aroused by the chemical test will be confirmed. 

Sugar. 
The detection of sugar in the urine does not always indicate the ex- 
istence of diabetes or kidney disease, and it is maintained by many authori- 
ties — among whom was the late Prof. J. W. Draper — that it is a common 
ingredient, and that it is often found after an excess of saccharine or starchy 
food has been taken, or after the use of chloroform, ether, turpentine, etc. 
In many diseases there are small quantities of sugar detected in the urine — 
in whooping cough, asthma, epilepsy, softening of the brain, abscesses and 
tumors of the cerebellum, nervous affections ; also in mental grief and 
shocks, after blows on the epigastrium, in dyspepsia, liver disease, temporary 
cold, uterine disorders and in certain hereditary conditions. But the Exam- 
iner should be thoroughly satisfied that it is a temporary condition before 
the applicant is accepted, and should examine the urine repeatedly before 
arriving at this conclusion. 



82 The Life Insurance Examiner. 

Diabetes is differentiated by a general decline of health, a dry and 
harsh skin, great thirst, voracious appetite, accompanied by the voiding of 
large quantities of urine loaded with sugar. Again, in the absence of gen- 
eral symptoms, if, after repeated examinations, sugar always exists in the 
urine, the onset of diabetes may be imminent and the applicant should be 
declined. 

Qualitative Tests. — Specific Gravity. — This usually exceeds 1.030, 
and if, in addition, a large quantity of urine is voided daily, diabetes may 
be suspected. 

Trommer's Test. — In all tests, boil, filter and remove the albumen, 
which negatives the test. Take a test-tube and put in it a drachm or two 
of urine ; add liquor potassae in excess, then slowly add a few drops of a 
solution of the sulphate of copper, which forms a bluish-white precipitate, 
the shaking of which produces a characteristic blue fluid. When this pre- 
cipitate ceases to dissolve, neither reagent can be in excess, and heat may 
be applied. Next boil, and when sugar is present a red or orange deposit 
of the suboxide of copper will be precipitated. Where the copper solution 
is added first in excess, some of the blue hydrated oxide of copper may 
remain unchanged ; and if too much liquor potassae is used, it may blacken 
the sugar. 

Caution. — " Saccharose," or cane sugar, as when ordinary sugar, or 
molasses, is put in urine to puzzle the novice, gives a black precipitate 
with Trommer's test. 

A Better Test. — The presence of animal sugar forms this red precipi- 
tate, but many other organic substances have the same effect. Tartaric 
acid is one of the substances possessing this property, and yet does not re- 
duce the copper by boiling ; it is therefore used in the following test : 

FEHLING'S Test.— Make the test fluid fresh as follows : Sulphate of 
copper, five grains ; neutral tartrate of potash, ten grains ; liquor potassae, 
two drachms. Mix these ingredients, and an intensely blue, clear fluid will 
be formed. Put a small quantity of this in the test tube and boil ; while 
at the boiling point add the suspected urine, drop by drop, until equal in 
quantity to the test fluid ; if sugar be present in quantity, it will form a pre. 
cipitate of a red or orange color. The copper and alkaline fluids should be 
kept in separate bottles until about to be used, so as to have the test fluid 
fresh. 

Small quantities of sugar, such as less than three parts in 1000, present 
various anomalies. In such cases the uric acid and coloring matters of the 
urine have a reducing power, and therefore the copper precipitate is never 
red, but yellow, or in fact any intermediate shade, from the deep blue of 
the test fluid, through green to yellow. Again, if the urine is highly phos- 
phatic, boiling with the alkaline solution may throw down the phosphates, 
forming with the copper deposit, reduced by the normal urinary ingredients 
at the same time, a precipitate resembling the deposit of copper produced 



The Life Insurance Examiner. 83 

by sugar. In that case we must decolorize the urine by passing it repeat- 
edly through a filter of animal charcoal. Also we must in all cases 
remove the albumin by boiling and filtration. 

The Bismuth, or Boettger's Test, may be used to confirm either 
of the foregoing tests, as follows: Take about a drachm of urine, freed from 
albumen, in a test-tube, and add an equal amount of liquor potassae, and 
then about two grains of the subnitrate of bismuth. Boil for a minute or 
two, and if sugar is present, the bismuth will be changed to some color 
between black and gray, according respectively to the large or small amount 
of sugar in the urine. 

Quantitative Tests, such as Fehling's volumetric method, and esti- 
mation by the polariscope, may be found described in books on this subject. 

Dr. William Roberts' Fermentative Test is generally used by In- 
surance Examiners to determine the number of grains of sugar present in an 
ounce of diabetic urine, as follows : ''(1.) Four ounces of urine are placed in 
a twelve-ounce vial, or special tube manufactured for this purpose, with a 
lump of German yeast of the size of a walnut. (2.) The vial is then loosely 
corked, or covered with a glass slide, and placed in a warm place to ferment. 
(3.) A companion vial filled with the same urine, say a three-ounce vial, is 
tightly corked and placed beside the fermenting vial. (4.) In about twenty- 
two hours, when fermentation has ceased, the two vials are removed to a 
cooler place. (5.) Two hours after — or twenty-four hours from the begin- 
ning of the experiment — the contents of the vials are separately poured into 
two cylindrical glasses, and the density of each is estimated. (6.) The 
difference in specific gravity of the two is thus ascertained, and every degree 
of density lost indicates one grain of sugar per fluid ounce of the urine 
examined." 

Physiological. — Prof. Witthaus, in his " Manual of Chemistry/' 
briefly sums up the metabolism of sugar as follows : 

'* The greater part of the glucose in the economy in health is intro- 
duced with the food, either in its own form or as other carbohydrates, which 
by digestion are converted into glucose; a certain quantity is also produced 
in the liver at the expense of glycogen — a formation which continues for 
some time after death. In some forms of diabetes the production of glu- 
cose in the liver is undoubtedly greatly increased. The quantity of sugar 
normally existing in the blood varies from 0.81 to 1.23 1 parts per thousand ; 
in diabetes it rises as high as 5.8 parts per thousand. 

" Under normal conditions, and with food not rich in starch and sac- 
charine materials, the quantity of sugar eliminated as such is exceedingly 
small — so small, indeed, that some observers have contested the fact of any 
being eliminated in health. It is oxidized in the body, and the ultimate pro- 
ducts of such oxidation are eliminated as carbonic acid and water. Whether 
or not intermediate products are formed, is still uncertain ; the probability 
being that they are. The oxidation of sugar is impeded in diabetes. Where 



84 The Life Insurance Examiner. 

this oxidation, or any of its steps, occurs, is at present a matter of mere con- 
jecture ; if, as is usually believed, glucose disappears to a marked extent in 
the passage of the blood through the lungs, the fact is a strong support of 
the view that its transformation into carbonic acid and water does not occur 
as a simple oxidation, since the notion that sugar or any other substance is 
1 burned ' in the lungs, beyond the small amount required for their nutri- 
tion, is scarcely tenable at the present day. 

"So long as the quantity of glucose in the blood remains at or below 
the normal percentage, it is not eliminated in the urine in quantities appre- 
ciable by the common tests; when, however, the amount of glucose in the 
blood surpasses this limit from any cause, the urine becomes saccharine, to 
an extent proportionate with the increase of glucose in the circulating 
fluids. The causes which may bring about such an increase are numerous 
and varied ; many of them are entirely consistent with health, and the 
mere presence of increased quantities of sugar in the urine is no proof, 
taken by itself, of the existence of diabetes. 

"In true diabetes the elimination of sugar by the urine is constant, un- 
less arrested by regulation of the diet, and not temporary, as in many other 
conditions. The quantity of urine is increased, sometimes enormously, 
and the specific gravity is high; the elimination of urea is increased abso- 
lutely. The quantity of sugar eliminated varies from 6.4 ounces to 12, and 
even 45, ounces in twenty-four hours. During the night less sugar is 
voided than during the day; the hourly elimination increases after meals, 
reaching its maximum in four hours, in proportion to the amount of food 
taken. It, is, therefore, obvious that, in order to make quantitative esti- 
mates of sugar of any clinical value, it is necessary to take the sample 
from the mixed urine of the whole twenty-four hours." 

Bile. 

Bile in the urine is generally due to liver disorders or obstruction of 
the biliary ducts, and jaundice usually coexists. The urine is greenish in 
color, usually acid, with a variable specific gravity, and often contains albu- 
min. 

PETTENKOFFER'S TEST FOR Bile. — Boil to precipitate the albumin ; 
when cool, decant into a clean tube and filter. Then place the tube into 
clean water, drop a piece of white sugar into the urine, and add slowly by 
drops two thirds of its bulk of sulphuric acid ; in from fifteen minutes to an 
hour a reddish-brown color is produced. 

HELLER'S Test. — Add a little white of egg or albumin ; coagulate 
with nitric acid, and a play of colors forms from yellow to reddish brown. 

Blood. 
Bloody urine is brown or red in color. Its reaction and specific gravity 
are variable. 



The Life Insurance Examiner. 85 



Heat -Test.— Boiling coagulates the albumin of the blood and entraps 
the blood discs, which form a dirty coagulum. 

SULPHURIC Acid changes the color of the urine to a reddish-brown, 
revealing the presence of haematin. The appearance of blood corpuscles 
under the microscope confirms the diagnosis. When blood appears in the 
urine it precludes insurance, and the cause must be ascertained. It may 
ensue from injuries, calculi, pyelitis, Bright's disease, tumors of the bladder, 
cystitis, hyperaemiaof kidney, nephritis ; also in purpura, scarlet and typhus 
fevers, malaria, cholera, etc. 

Chyle. 

Chyle in the urine shows a white color; reaction and specific gravity 
variable. It is a disease of the Tropics, the urine often resembling jelly, 
containing fat and albumen. 

Test. — Pour into the test-tube half an inch of sulphuric ether to sepa- 
rate the fat, add the urine ; take out some of it with a pipette and put on a 
watch-glass ; evaporate by heat and the stain of fat remains. 

Mucus. 
Mucus in some quantity always exists in the urine. It may be pre- 
cipitated with acetic acid. When iodine is added to the acidulated urine, 
the mucin is colored and the epithelial cells are rendered distinct. Irritation 
of the urinary tract causes an increase of mucus ; inflammation is indicated 
by pus in the urine. 

Pus. 

Pus produces a milky appearance of the urine and causes a dense white 
sediment. The urine quickly becomes alkaline, and contains albumin in 
proportion to the amount of pus present. Acid urine containing pus, 
when freshly voided, indicates that the pus came from the kidneys. When 
alkaline, it is inferred that the pus originates in the bladder. It may 
accompany gonorrhoea, gleet, leucorrhcea or mucous abscesses. Pyuria of a 
cystic or renal origin is of more moment. 

Test. — Allow the urine to settle ; pour off the supernatant fluid and 
add liquor potassae. The pus is changed into a viscid gelatinous mass, 
adhering to the tube. Pus corpuscles are seen under the microscope. 

Urea. 
Urea constitutes seventy or eighty per cent of the nitrogenous con- 
stituents of the urine and represents the ash of those substances which have 
been burned up in the animal economy. The estimated amount of urea 
excreted by a healthy man is 512.4 grains per diem, the quantity fluctuat- 
ing with the amount of nitrogenous food consumed and the rate of tissue 
transformation. Excessive muscular exercise increases it, but when the 
kidneys reach their limit of excretory power, it passes off in diarrhoea 
through the bowels. 



86 The Life Insurance Examiner. 



A diet of fat and farinaceous food, in addition to nitrogenous principles, 
lessens the amount of urea and the destruction of tissue. Excess of drink- 
ing water increases it, especially when taken during meals ; table and 
other salts have the same effect. Moderate warmth diminishes it ; fever 
increases it. 

Clinical Significance. — In the urine it exists in the proportion of 15 to 
20 parts in 1000 ; in the blood, .016 parts in 1000. 

Excessive Excretion of Urea. — When the amount exceeds two per cent 
it indicates fever, or that the person drinks too little water to dissolve and 
eliminate the nitrogenous proximate principles of the body, or that he has 
been perspiring profusely. Azoturia is the name applied to this condition. 
In some cases it is accompanied by a corresponding increase in the excre- 
tion of water ; in others both the relative and absolute quantity is greater, 
and crystals of the nitrate of urea appear upon the addition of nitric acid. 
This increase may occur temporarily without causing symptoms; but when 
it persists, it is usually followed by derangement of the stomach and bowels, 
nervous disorders, acidity, flatulency, languor, restlessness and a frequent 
desire to urinate. There is azoturia in diabetes, and some suppose it to be 
the first stage of that disease. The specific gravity will be about 1.030 
or more. 

Diminished Excretion of Urea is of much graver import and may merge 
into uraemia. It may be caused by extreme emotion, excessive drinking, ex- 
posure to chill. It is diminished in Bright's disease with contracted kidney, 
in some chronic organic affections, and often preceding the paroxysms of 
rheumatism, gout and asthma. 

TESTS FOR Urea. — A rough test is furnished by the readiness with 
which crystals of the nitrate of urea form after adding nitric acid. These 
crystals do not form readily unless there is an excess of urea. Add to the 
urine one-fourth its bulk of nitric acid in a test-tube immersed in cold 
water, and the relative proportion of crystallized nitrates is easily calulated. 

Quantitative Test. — Use the hypobromite solution recommended by 
Russel and West. This solution is made by dissolving 100 parts of caustic 
soda in 250 parts of water, and adding when cold 25 parts of bromine. 
Keep the bromine separate until the test is made, as the solution must 
be fresh. 

The test depends on the fact that urea mixed with alkaline hypobrom- 
ites is decomposed and yields nitrogen, from the amount of which gas the 
quantity of urea is estimated. The necessary apparatus consists of a tube 
in which the urine is placed (four or five times as much of the solution 
being added), and a pneumatic trough with a measuring tube graduated to 
show the amount of nitrogen gas. 

Phosphates. 
Two kinds of phosphates are found in the urine — phosphate of lime 
and ammonio-magnesian, or triple phosphates. About six parts in 1000 of 



The Life Insurance Examiner. 



87 



normal urine consists of phosphates ; when they are in excess, the urine is 
generally of a light color. These salts are derived from the food and 
tissues, and are united with the organic, nitrogenized, proximate principles. 
Their quantity in the urine depends on the food eaten and the drain on the 
nervous system from study or sexual excesses. 

Clinical Import. — When excreted in excess, there is danger of phos- 
phatic calculus. Disease changes its proportions. Increased elimination 
occurs in inflammatory diseases of the nervous system, acute mania, delirium 
tremens, paralysis, diseases of the bones, and rickets. It is generally dimin- 
ished in Bright's disease, gout, rheumatism and pneumonia. 

Tests, — Heat gives a cloudy precipitate, which nitric acid dissolves. 
The phosphates are deposited when the urine becomes alkaline and fer- 
ments. Under the microscope, phosphate of lime is amorphous. The triple 
phosphates occur in rhombic prisms, which readily dissolve in acetic acid, 
while oxalate of lime crystals do not. 

Quantitative. — A rough estimation is made by making some urine alka- 
line with ammonia and adding an ammonio-magnesian solution to it. If 
the amount already in the urine is normal, a precipitate at once occurs; if 
the normal amount is lacking, this precipitate is delayed. 

Composition of Urine. 

Water, about 940 parts in 1000; urea, about 30 parts in 1000; salts, 
about 6 to 10 parts in 1000; uric acid, about 1 part in 1000; extractives, 
about 23 to 26 parts in 1000. 

Chemical Examination of Urine. 





Tests. 


INGREDIENTS. 


Color. Reaction. 


Specific 
Gravity. 


Heat. 


EK" | othCTTes ' s - 


Ammonium Car- ) 


Varies. 
\ aries. 
Varies. 

Varies. 

Varies. 

Brown. 
Brown. 
White. 


A Ik 'line 

Varies. 

Varies. 

Varies. 
Varies. 

Varies. 

Varies. 

Varies. 


Varies. 

High. 

Varies. 

Varies. 
High. 

Varies. 

Varies. 

Varies. 


White 
precip. 

White 
precip. 


E ff erves- 
cence. 

Nitrate 
crystals 




bonate ) 

Excess of urea. . . 

Phosphates ...... 

Albumen 

Sugar 


Crystals, with oxalic acid. 
Soluble in nitric acid. 


White 
precip. 


Mercury bichloride or tannin 
causes a precipitate. 

Trommer's or Fehling's test. 
Pettenkoffer's or Heller's test. 
Microscopic and iron test. 
Separation of fat by ether. 


Bile 

Blood 

Chyle 


Prec. of- 
ten wh. 

Precip. 
dirty. 

Precip. 
white. 


Precip. 
colored. 

Precip. 
dark. 

Precip. 
white. 





ss 



The Life Insurance Examiner. 



Microscopical Examination of Urb 

Hints. — Shake the urine thoroughly, add a little salicylic acid to pre- 
vent decomposition, pour into a conical vessel, cover, and allow it to settle 
for half a day or longer. When about to examine it, prepare a clean glass 
slide, and upon this place a few drops of the urinary deposit by means of a 
pipette ; cover the drops with a thin glass disc, and examine with a one- 
quarter or one-fifth inch objective lens. 

Search for the different crystals, amorphous urates and phosphates, 
epithelial cells, fat globules, mucus, pus and blood discs ; and watch with 
extra care for tube casts, examining many specimens from the same deposit 
before any conch: s :: a is reached, especially if the urine contains albumen, 
as these abnormal ingredients generally coexist. 




Five classes of minute bodies are usually met with in sediment de- 
posited from urine. These are: First, crystals ; second. casts : third, mucus, 
blood and pus corpuscles; fourth, fungi, or minute vegetable organisms: 
fifth, accidental extraneous matters. 

C7.y-t.--L5. — Normal urine should never contain a sediment. Appear. 
ance of crystals within twenty-four hours after the urine has been passed, may 
be accepted as indicating a non-healthy condition of the system, whether 
temporary or permanent. The crystals most frequently met with are, uric 
acid, ammonia, oxalate of lime and an amorphous deposit of the urates. 

I. URIC Acid. — This is the product of a metamorphosis of tissue. A 
characteristic test for it is effected by the addition of a few drops of nitric 
acid to the suspected deposit, which has previously been placed in a capsule, 



The Life Insurance Examiner. 



89 



the mixture is then to be strongly agitated ; a drop of ammonia is added, 
which instantly produces a rich purple tint. But both uric acid and the 
urates can be more easily and quickly determined by the microscope. 

Crystals of uric acid, notwithstanding that they vary in size and form, 
are very readily distinguished. To obtain them rapidly, a portion of the 
suspected deposit is dissolved in a drop of liquor potassse, and this alkaline 
solution is then treated with acetic acid, and in the lapse of a few hours the 
crystals of uric acid will be formed. 

When we find the amount of acid diminished in the urine, we suspect 
the more advanced stages of Bright's disease, but an increase should lead 




Beautiful crystals of triple or ammonio-magnesian phosphate and spherules of urate 
of soda, x 215. (After Beale.) 



us to suspect a rheumatic diathesis, a tendency to acute inflammation, gas- 
trie or hepatic disorders or intemperance. 

Urates. — The pathological conditions in which the urates are found, 
are much the same as those in which uric acid occurs. 

The urates consist principally of urate of soda and of ammonia, and of 
small quantities of urate of lime and magnesia, and the deposits formed on 
their precipitation are usually pink, brown or white. They are dissolved 
with great readiness on heating the urine. Acids decompose them. Un- 
der the microscope, the urates are seen to be either irregular amorphous 
particles, round globules or needle-like crystals. Urate of soda is shown 
in the shape of round globules of various size, from some of which fine 
needles project. Urates of soda and of ammonia are usually globules 



90 



The Life Insurance Examiner. 



and crystals, while the irregular particles are supposed to represent urates of 
lime and soda. 

Urine containing a sediment of urates is usually very acid, or not infre- 
quently becomes so. In urine which has become cold, these deposits are 
thrown down much more abundantly than in that which is freshly passed. 

Triple Phosphates. — These are generally beautiful microscopic ob- 
jects, but their appearance varies greatly with the rapidity of their crystal- 
lization. Their color is produced by a combination of phosphoric acid with 
soda, lime and magnesia ; and they are derived in part from food and in 
part from changes in albuminous substances — specially of the nervous 
structures. 




Crystals of triple phosphates. 9 Mg0NH 4 P0 5 + I2aq. In the form of triangular 
prisms, wiLh obliquely truncated extremities, as they frequently occur in urine. In 
many cases the crystals are four-sided. Not unfrequently the shaft of the crystal is so 
short that the two triangular extremities are seen quite close together, and the crystal, 
without care, might be mistaken for an octahedron. x 45. (After Beale.) 



I-!-- of an inch 
1 000 



1 I 



These are kept in solution by the acidity of the urine, but as soon as this 
becomes alkaline, they become precipitated. They are often met with in 
heavy deposits containing purulent urine, resulting from chronic catarrh of 
the bladder, or in cases of temporary or permanent paralysis; and they are 
found also in many affections in which the vital powers have become seri- 
ously lowered and the acidity of the urine diminished. 

Applicants laboring under great general debility and indigestion, 
associated with an impaired tone of the nervous system, usually present 



The Life Insurance Examiner. 91 



this symptom, and it is very common in men depressed by mental toil or 
anxiety. 

This is also found when an excess of animal food is taken into the system 
during very active exercises, and in the rheumatic diathesis. It is increased 
in all inflammatory diseases of the nervous system, in paralysis, in severe 
nerve lesion, in acute mania; and is diminished in Bright's disease and 
gout, in rheumatism and in most febrile and inflammatory affections. 

Oxalate of Lime. — The presence of crystals of this sort is noted in 
morbid conditions, and is generally found in persons who are weighed 
down by excessive anxiety, or who have given way to excessive indulgence or 
masturbation. Dyspeptic persons, or those who suffer from uneasiness after 
meals, or those troubled with frequent seminal emissions and irritation 
of the bladder, are apt to pass these crystals in quantity. These applicants 
are usually either very irritable or very dejected ; frequently they complain of 




Dumb-bell and octahedral crystals of oxalate of lime. One 
very large octahedron is seen at the right hand side of the fig- 
ure, x 215. vAfter Beale.) 

loss of memory and of dull pain across the loins ; they are very liable to boils 
and carbuncles, apt to be emaciated, and are generally out of health. 

The urine containing this crystal is usually of high specific gravity, and 
shows an increase of urea, and ordinarily contains a cloudy deposit. 

Persons in this condition are usually said to have oxaluria, although its 
existence as a separate affection has been denied. 

Oxalate of lime may also be detected in the urine of persons after 
eating rhubarb plant; and may be also found in the urine of persons 
recovering from severe acute maladies, but it is only found in very small 
quantities in the urine of healthy persons, so that the presence of a few 
crystals cannot be looked upon as of the least practical importance. Under 
the microscope, it appears in well-defined octahedra, varying in size, and 
also dumb-bell shaped, the former being more common. 

Casts. — These bodies are minute tubular masses of coagulated matter, 
which form in diseased renal tubules and are washed down into the bladder 
and voided in the urine. Their size corresponds to that of the tubes in 



The Life Insurance Examiner. 




m, casts of large diameter, containing granular matter scattered through them i 
b % a very long, dear and perfectly transparent cast, containing only a few minute oil i 
here and there, c, dark granular casts, some of them containing a few oil globuies, d, large 

-^in ::' rTir.-liT-?::tr riiy ::' :'-t~ irreir.- - !L-;e rrur. - ir :el".= _•!-: ::' :"-e = e ire 
derived from the mucous membrane co ve ring the gians. e, cells of renal epithelium, darker 
£Jid — re graurulau :.ir. _-.i. - — vs? : : ? _ _i— : _i eri:~euu— . ::: rir'.v fr; — :r_e :: :.-.e 
f:llirle; ::' :ue -u::u = -e-':.-n» ::* tie r_idier r free ::. £.: "rules. ■': . r-:ru:us : : ;:::;- 
fibre, z, portion of feather, x 215. -r^W of aa inch x 215. t. After Beak.) 



The Life Insurance Examiner. 



93 



which they are formed, and they differ in character according to the type 
and stage of the disease in which they occur. 

Varieties. — They are named exudative or fibrinous, desquamative or 
epithelial, fatty, granular, and hyaline or waxy. 

Exudative OR FlRRiNOUS Casts are masses of coagulated matter 
from the uriniferous tubules of the kidney, to which epithelial cells may or 
may not adhere. 

They are more commonly found during the first stage of the inflamma- 
tory form of Bright's disease. 

Desquamative or Epithelial Casts are detached pieces of the lin- 
ing membrane of those tubules, the cells being opaque, like unhealthy 
epithelium. 




Casts containing oil from the urine of a case of fatty degeneration of the kidney of long 
standing. Many cells of epithelium contain no oil. x 215. (After Beale.) 

Fatty Casts are those plugs of coagulated matter whose walls are 
covered with minute globules of oil from fatty degeneration. 

Granular Casts are seen when the process of fatty degeneration goes 
on until the oil globules appear subdivided and present a granular aspect. 

The fatty and granular casts are common to the second and third 
stages of inflammatory Bright's disease, and indicate the large white gran, 
ular kidney. 

Hyaline or Waxy Casts are extremely transparent in appearance, 
showing only the outlines, and contain no fat, epithelium or granules. 
They are produced by the exudation of fibrin through the walls of the 
diseased vessels into the uriniferous tubules. They may be absent for a 
few days and then reappear. They are found in the stage of atrophy of all 



94 



The Life Insurance Examiner. 



forms of Bright's disease of the kidney, and do not, as at first might 
appear, solely indicate waxy kidney. Blood corpuscles and crystals may 
appear on the surface of or imbedded in casts. 



! 





Crystals of triple phosphate ; the prismatic portion 
of which is defective, and casts containing oil from the 
urine of a patient suffering from chronic nephritis, 
with partial fatty degeneration. (, After Beale.) 

EPITHELIAL Cells of the different varieties may be found in the field 
of the microscope, and are classified as follows : 
Vaginal Epithelium. 
Normal Renal Epithelium. 
Atrophied Renal Epithelium. 
Bladder Epithelium. 
Epithelium from the Pelvis of Kidney. 




Long, narrow threads of viscid mucus ; with spermatozoa in casts of the 
seminal tubules, * 215. (Beale.) 

When renal epithelium, blood discs and tubular casts are found 
together, either acute inflammation or intense congestion of the kidneys 
may be inferred. 



The Life Insurance Examiner. 



95 



4Kfc 



& 







Epithelium from the 

convoluted portion of the 

urin if erous tube, a, 

treated with acetic acid. 

x 215. 



Epithelium from the 
pelvis of the h„man kid- 
ney, x 215. 



^m 



Epithelium from the 
ureter, x 215. 






Epithelium from the 
urethra, x 215. 




m 



Bladder epithelium a, from the general 
surface, b, from the fundus c, scaly epithel- 
ium from the bladder, x 215. 




Vaginal epithelium from the urine, x 215. 




Epithelium from the bladder, showing the 
hollows in some of the large cells into which the 
subjacent columnar cells fit. 




Epithelium from the vagina. 




Young epithelial cell from the bladder, under- 
going division, x 700. 





Formation of pus from terminal matter of 
epithelial cells, x 215. 



Too o£ an inch L 



215. 



x 700. (After Beale.) 



96 



The Life Insurance Examiner. 



Blood in the Urine, if considerable in amount, gives it a reddish 
or smoky appearance. When it originates from the kidneys, it is diffused 
throughout the urine ; when from the bladder or urethra, blood clots are usu- 
ally found. The blood corpuscles are distinguished from other cells in the 




IT&tfgKrfir* 




u 38 



•wiih crystals of triple 



urine by their lack of nuclei and slight refractive power. The clinical pur- 
port of this condition depends upon its source. It may ensue from lesions 
of the kidneys, or bladder, or urethra — such as traumatism, nephritis, renal 

. raemia. pyelitis, calc :i:is. etc., or from constitutional dh: 

as cholera, scarlet fever, purpura, etc. 

Pus IX THE URINE imparts a milk}* appearance. When the voided 
urine is acid, the origin of the pus is inferentially in the ki:; :' alkaline, 

in the bladder. 

Pus is distinguished from other cells by their larger size, granular 
appearance, and the fact that acetic acid makes their nuclei very distinct ; 
and if the same acid is added in e:: e cell wall and contents disac 

It is difficult to infer its sour: 




Pns corpuscles from mine, 
x 215. (Beale.) 



i - ■ . : 









.- _ : : . - - - -. i "_ t t - i. : i± i - z • : z. 

by acetic add. > ;:j (Beale.) 



Spermatozoa in the Urine impart a mucous deposit, if in sufficient 
quantity, and consist of minute bodies, rh> of an inch long, with an oval 



The Life Insurance Examiner 



97 



head and caudal extremity. They are seen in the urine after sexual inter- 
course, seminal emissions, etc., and have a trivial clinical import in most 
cases. 

FUNGI. — The vegetable organisms most often observed in the urine 
are torula cervisiae found in diabetes; penicilium glaucum, found in acid 
albuminous urine ; and sarcinse, whose origin is obscure. 

Extraneous Matters most common are fibres of cotton, wool or 
linen and the dust of sweepings. 




The sugar fungus from diabetic 
urine, x 240. (Beale.) 

Microscopic Examination of Urinary Deposits. 





Tests. 


ingredients. 


Color. 


Heat. 


Hydrochlo- 
ric Acid 


Nitric 
Acid. 


Other Tests. 


Nitrate of ammonia. . 
Phosphates 


White or 

pink. 

White. 

White. 

Red. 

Cloudy. 

Red. 
Yellow. 
White. 


Soluble. 
Insoluble. 
Insoluble. 
Insoluble. 

Insoluble. 

Insoluble. 
Insoluble. 
Insoluble. 


Soluble. 
Soluble. 
Soluble. 
Insoluble. 

Insoluble. 

Insoluble. 
Insoluble. 
Insoluble. 


Soluble. 
Soluble. 
Soluble. 
Soluble. 

Insoluble. 

Insoluble. 
Insoluble. 
Insoluble. 


Precipitates when cool. 

Gelatinous precipitate 
when ammonia is added. 

Granular precipitate when 
ammonia is added. 

Deposit on a watch glass, 
add two drops of nitric 
acid, evaporate, and 
when cool add ammonia; 
it. turns to a rich purple 
color ; called the murex- 
ide test. Shake, and de- 
posit will mix. 

Deposit will not mix by 
shaking. 

Di^cs under microscope. 

Microscopic appearances. 

Deposits hexagonal plates 
when cool. 


Oxalate of lime 


Mucus 


Blood 


Pus 


Cystine 





PART III. 

DISEASES RELATING TO LIFE INSURANCE. 



HEREDITARY INFLUENCES. 



Transmission of Disease. 



A TENDENCY to certain diseases may be transmitted from generation 
to generation, which the Examiner must be able to detect by making 
comparisons between the family record, previous history and pres- 
ent physical condition of the applicant. 

Collateral Physiological Conditions. 

i. The relative ages of parents at the time of the applicant's birth 
should be considered a factor in the estimation of his future expectation of 
life. Great disparity of age militates against the offspring, even though 
other considerations are favorable. In order to beget vigorous children, 
the sexes ought to be of about the same age and in the prime of life. In 
case of marked disparity of age, the progeny is apt to inherit general de- 
bility or some particular disease from the weaker parent. 

2. Consanguinity, or a too close blood relationship between father and 
mother, deteriorates the power of resisting disease in their issue. The un- 
written law of life insurance should forbid marriage of cousins of the first 
degree, and place no bar against the descendants of the man who marries 
his deceased wife's sister. 

3. The hereditary tendency to disease may have been outgrown, or 
not yet reached, according to the affinity existing between certain ages 
and certain diseases, as pointed out in the section on age. This inherited 
taint often remains latent for many years, or several generations, only to 
reappear when certain exciting causes enliven the dormant germs of disease. 
The family inclination to disease is more manifest among brothers and 
sisters than between parents and children. 

4. Sameness of physical organization between father and mother, and 
likeness in the conditions under which they were reared, conspire to pro- 
duce inferior progeny. 

5. Intermarriage of different races is physiologically beneficial, unless it 
necessitates an extreme change of climate or manner of living. As a rule, 



The Life Insurance Examiner. 99 

the vigorous children of healthy English parents, born in tropical regions, 
pine away unless removed to a temperate zone. 

6. Longevity of ancestors. The observation should extend over three 
generations. Longevity of both grandparents is most desirable, but the 
old age of grandparents on the maternal side is more apt to be reproduced 
in the grandchildren than that of the paternal side. Causes of death in 
the case of grandparents are essential, and any existing diathesis should, if 
possible, be traced back. At the same time, we must remember that the 
progress of civilization, hygiene and medical science has remarkably in- 
creased the average of human life, and still tends in the same direction. 

7. Direct and indirect heredity. The direct implies the transmis- 
sion of a specific taint from one generation to another. Indirect heredity 
means the production of constitutional peculiarities, not allied to organic 
disease, but due to impressions made through the mother during gesta- 
tion which influence the subsequent development of the child. This 
is called the law of atavism, when certain qualities are traced back several 
generations. The intelligent use of this law has resulted in greatly improv- 
ing domestic animals, and might be applied with equal benefit to mankind 
if stirpiculture were possible in organized society. 

Transmission of Consumption or Tubercle. 

The following are some of the theories, aside from the germ theory, 
which have been advanced by various authors with reference to this 
most prevalent constitutional taint. Discussion is purposely omitted : 

1. Predisposition to it is more frequently inherited than acquired. 

2. Maternal transmission is more virulent than the paternal. 

3. Two consumptive parents intensify the tendency. 

4. To transmit the taint, either one or both of the parents must be 
infected with the disease previous to gestation. Nevertheless, as an excep- 
tion to this rule, the second generation often escapes and the third inherits 
the taint from the first generation — grandchildren from grandparents, 

5. The adverse environment of the individual often starts up a fatal 
attack, after almost a lifetime of immunity from symptoms of inherited 
tendency. 

6. Any wasting disease in the parents, especially if in advanced life, 
may superinduce this fatal malady in their children. 

7. The first-born children are not as susceptible as those born after the 
prime of life, when the disease becomes developed in either or both of the 
parents. 

8. Inherited consumption usually appears before the third decade of 
life is completed ; the acquired form develops later in life. 

9. Hard labor and exposures hasten its development. 

10. The most robust physiques do not escape this latent tendency. 



ioo The Life Insurance Examiner. 



ii. Consumption as a cause of death in the family record should be 
perseveringly sought out by the Examiner. 

12. Among children, tubercle generally attacks the brain or abdominal 
organs before it appears in the lungs. Tuberculosis should, therefore, be 
suspected as the cause of death, in lesions of the brain or abdominal organs, 
among the deceased brothers and sisters of the applicant. 

13. The relative virulency of the consumptive dyscrasia is best meas- 
ured by its effects upon the applicant's immediate family. 

14. Liability to the disease, when inherited from the father manifests 
itself most actively from the tenth to the thirtieth year. From forty-five 
to sixty-five the danger is slight. 

15. Liability from the mother is greater than from the father, the disease 
being of a more virulent type, but the period of susceptibility is shorter, 
say between the ages of fifteen and thirty, with few deaths after forty. 

16. When two deaths in a numerous family have occurred, the one a 
parent beyond forty and the other a brother or sister below the applicant's 
present age, if the examination presents no other objection, the risk is fair. 

17. The single death of brother or sister, when other points of family 
history and personal examination are favorable, should not prevent 
insurance. 

18. Two deaths of brothers or sisters older than the candidate, unless 
the individual condition and environment are most desirable, should reject. 

19. The death of both parents, even at an earlier age than the present 
age of the applicant, should reject. 

20. Three or more deaths in the immediate family, comprising a parent 
and two or more brothers or sisters older than the applicant, even though 
personal points favor, should reject. 

21. When the applicant exhibits the tuberculous diathesis, although 
the family record shows no death from consumption, it should reject. 

22. When the infant mortality in the family has been great, and the 
surviving members, including the applicant, are quite young, or he is the 
only surviving member, the risk is hazardous. 

23. The death of a grandparent and parent in the same line proves 
that the taint exists in the applicant, and might be developed by any excit- 
ing cause, and renders the risk hazardous. 

24. When the applicant resembles the tainted parent, though disease 
is more transmissible through the mother, the risk is hazardous. 

25. When both parents have died comparatively young, the one from 
phthisis, and the other from cancer, abscess, erysipelas, intemperance, heart, 
kidney or brain disease, the applicant inherits the taint of one or both 
parents, and should be deemed a hazardous risk, 

26. Deaths in the immediate family should make the Examiner suspect 
tuberculosis as a cause of death among more distant relatives, such as uncles, 
aunts, grandparents, etc. 



The Life Insurance Examiner^ ioi 



2J. Pplicies for limited periods may be issued in the case of some risks 
classed hazardous, when approved by the executive officers of the home 
office after receiving full information from the Medical Examiner. 

28. Transmission of the scrofulous diathesis, which is akin to tubercle, 
as an expression of deficient and defective nutrition, must be detected and 
taken into account by the Examiner. 

Transmission of Cancer. 

1. Cancer is a specific disease, and in regard to the frequency of trans- 
mission stands next to consumption 

2. Cancer and tubercle may coexist, but cancer usually excludes the 
latter. 

3. The development of cancer generally occurs between thirty-five and 
fifty, when the vital forces begin to wane. 

4. Females are more liable than males, and the parts most frequently 
affected are the generative organs and breasts. 

5. When both taints, the cancerous and tubercular, exist in his family, 
the applicant should be rejected. 

6. When two or more deaths from cancer have occurred in the appli- 
cant's family, he should be rejected. 

7. The death of one parent should not necessarily reject. 

8. Sporadic cases of cancer, though rare, may be encountered. 

Transmission of Gout. 

1. Hereditary tendencies can be traced in more than one-half of the 
cases. 

2. When the gouty diathesis manifests itself before the age of thirty- 
five, the risk is hazardous. 

3. Where both parents, or a parent and grandparent, and an uncle or 
aunt, have had gout, the risk is hazardous. 

4. When one parent or a grandparent has suffered from gout, the 
applicant himself having never had an attack, and being of good habits, if 
the physical examination proves satisfactory, he should be eligible for 
insurance. 

5. If the applicant ha? passed the age of thirty-five without showing 
any symptoms of the disease, and his physical examination is unobjection- 
able, even though two ancestors exhibit a history of gout, he is eligible for 
insurance. 

6. The inherited diathesis is not always manifested by a typical attacnc 
of gout, but by degenerations in the heart, blood vessels, kidneys and 
nervous system. 



io2 The Life Insurance Examiner. 

Transmission of Rheumatism. 

i. About one-third of the cases reveal transmission. 

2. The liability to it is most marked between fifteen and thirty ; after 
fifty it is slight. 

3 ? Acute articular rheumatism, or the unmistakable rheumatic diathe. 
sis, is referred to here, and not other and minor forms of rheumatism. 

4. If the rheumatic attacks are recurrent and metastatic, the applicant 
should be rejected. 

5. One or more attacks, coupled with a family history of acute articular 
rheumatism, renders the risk hazardous. 

6. If no attacks appear before thirty-five, and the applicant is accept- 
able in other respects, he is eligible for insurance. 

Transmission of Syphilis. 

1. Syphilis may be inherited from father or mother, and causes great 
infant mortality. 

2. The force of the transmitted disease spends itself with advancing 
years under favorable environment and treatment, so that an applicant who 
presents no present traces of the disease, if unobjectionable in other re- 
spects, is eligible for insurance. 

3. The hereditary form is less objectionable than the acquired form, but 
any candidate presenting decided marks of this disease, thus proving that 
radical curative treatment has been neglected, is a hazardous risk. 

4. The acquired form is more disastrous; and any candidate presenting 
symptoms of secondary or tertiary syphilis at the examination, should be 
rejected. 

5. Syphilis of either variety is capable of complete cure, and the candi- 
date who has undergone the requisite treatment for two years, and has 
shown no relapse in subsequent years, is eligible for insurance. 

6. Some of the objective symptoms of syphilis are as follows : Skin 
eruptions ; enlarged lymphatic glands in the neck and groin ; alopecia ; 
scars on skin or patches in the mouth and throat ; onychia; periosteal nodes 
on the bones, especially of the shin; rheumatic pains in the bones and 
joints, worse at night, etc. 

Transmission of Nervous Diseases, 
insanity. 

1. Cerebral diseases, such as apoplexy, paralysis, epilepsy and insanity, 
are often inherited. 

2. Hereditary insanity presenting itself in the family record or person of 
the candidate, other things being equal and favorable, lessens the expecta- 
tion of life about one-fifth, and should render the risk hazardous. 



The Life Insurance Examiner. 103 

3. The indirect risk of shortening life from insanity consists in its indi- 
cation of central nervous diseases, and the greater liability to accidental 
death. 

4. Incidental or temporary insanity may be differentiated, and should 
not always reject. 

5. The same form of cerebral disease is not always transmitted, but 
epilepsy may follow insanity, or vice versa. 

6. When the family record of cerebral diseases is poor, and the personal 
examination of the candidate is below par, he should be rejected. 

7. The Examiner must be on the alert to detect cases of incipient or 
masked insanity. 

8. Transmission occurs in one-third to one-half the cases of insanity. 

9. The tendency to insanity may have been outgrown, or not yet 
arrived at, according to age and condition. 

10. The children resembling the affected parent in physical conforma- 
tion and appearance are more liable to the disease. 

11. Baillarger's remarks on atavism are reliable. 

(a.) Transmission of the mother's insanity is more serious than that of 
the father, because her disorder is more frequently hereditary and because 
she transmits it to a greater number of children. 

{b) Girls are more likely to inherit the mother's insanity ; boys, the 
father's. 

(t\) Transmission of the mother's insanity is scarcely more to be feared, 
as regards the boys, than that of the father. 

(d.) The mother's insanity is twice as dangerous to the daughters. 

12. The insanity of brothers and sisters establishes the family proclivity, 
more than that of parents. 

13. The environment and personal habits of the applicant will lead the 
observant Examiner to suspect the appearance of inherited tendencies in 
the future. The occupation, domestic or civil troubles, intercurrent dis- 
eases, laborious pursuits, evil courses, intemperance, emotional excitements, 
etc., all tend to develop the family predisposition. 

14. The dread of insanity, as Bucknill and Tuke remark, in many fam- 
ilies of insane tendencies, is so great as to constitute, in itself, a morbid feel- 
ing sufficiently strong to mislead the observation, warp the judgment, and 
cause concealment and falsehood towards those who should command per- 
fect confidence. 

15. The melancholic temperament is prone to insanity, and the follow- 
ing symptoms are usually presented : The features are impassive and im- 
mobile and the expression is moody or sad ; the complexion is rarely clear 
and healthy, the skin is sallow, hard and dry, or cool and clammy ; the 
eyes are fixed, or staring, and the glance is askance, uneasy and suspicious ; 
dyspepsia and constipation are complained of, and the urine is scanty and 
loaded with lithates; the pulse is not strong. 



104 The Life Insurance Examiner. 



i 6. A more nervous temperament will present less obvious symptoms 
of insanity. There iz more activity of manner and vivacity of features. 
They are loquacious, have flashing eyes ; the skin is dry and pallid and 
florid by turns ; there are derangements of secretions and digestion, and a 
tendency to emaciation. 

17. Defective nutrition is held by many high authorities to be the chief 
factor in the etiology of insanity. 

18. All diseases which impair the constitution and impoverish the 
blood tend to awaken the predisposition. 

19. Still, the worst cases of insanity often enjoy vigorous health. 

20. To form a correct opinion in some of these incipient cases will tax 
the highest powers of observation and judgment. 

Transmission of Epilepsy. 

1. Definition. — According to most recent authorities, an epileptic con- 
vulsion is the symptomatic expression of a complex derangement of the 
cerebral collection of nerve-centres, the location of the central disorder, and 
its nature being inferentially determined by the character of the motor and 
sensory phenomena. 

2. Inherited transmission accounts for about thirty or forty per cent of 
cases of epilepsy. 

3. The following diseases, in their order, in parents predispose to epi- 
lepsy in the offspring : Insanity, consumption, alcoholism, syphilis, cranial 
malformation, some neurosis. 

4. The hereditary form of epilepsy usually begins before the twentieth 
year ; in fact, at an early age. 

5. Before the tenth year, in twenty-nine per cent of 1450 cases from all 
causes, epilepsy makes its appearance. 

6. Between the tenth and twentieth years, over one-third of 1288 cases 
from all causes begin to develop. 

7. According to age and sex, the result of 980 cases of general epilepsy 
is as follows : 

Dr. A. M. Hamilton's Table. 

Age. Females. Males. 7: :;'.. 



Under 10 

Between 10 and 20 

Between 20 and 30 

Between 30 and 50 

Over 50 



Total. 



103 


95 


: - 


171 


97 


::5 


145 


92 


239 


Si 


136 


217 


11 


49 


: : 


511 


469 


r'-'- 



8. Females under thirty are almost twice as liable as males. 



The Life Insurance Examiner. io: 



9. Males over thirty are twice as liable as females. 
% IO. The children of syphilitic parents develop epilepsy later in life than 
those whose parents suffered from alcoholism. 

11. Among males, when epilepsy appears late in life, we almost always 
find syphilitic or other cerebral lesion. 

12. Females affected with the disease at an advanced age generally 
present a history of migraine or menstrual derangement, and the convul- 
sions are apt to partake of a hysteroid character. 

13. Confirmed epilepsy should always reject the applicant, for two 
reasons ; first, because there always exists physical and mental impairment 
of health, and, secondly, on account of the danger of accident during the 
convulsions. 

14. Even after a long period of immunity from attacks, the danger of 
recurrence is omnipresent and the risk is hazardous. 

Hereditary Alcoholism. 

Two forms are recognized. 

First Form is the direct transmission of the disease or defect from 
parents to children. 

1. This hereditary propensity is apt to show itself in early life, and may 
be intensified at the period of puberty and the menopause. 

2. Instances are numerous in which the habit begins late in life ; and 
again, when children are reared and educated away from their parents, under 
a favorable environment, and yet develop the propensity unerringly. 

3. The hereditary tendency is not always manifested in a desire for 
drink. 

4. It may consist in feebleness of nervous constitution ; such victims 
may be moral imbeciles, with an insatiable craving for nervous stimulants 
of all kinds and constant excitements. 

5. The general laws of heredity are illustrated in the transmission of 
alcoholism. The tendency may come down from father to son, or skip one 
or more generations, assuming in the intermediate periods some other form 
of nervous disorder. 

The Second Form is indirect, and consists, not in the inheritance of 
the taste for alcohol, but in a morbid tendency to mental and nervous dis- 
orders of a different kind, such as epilepsy, hysteria, the various forms of 
insanity, every degree of arrested mental development, from feeble-minded- 
ness to complete idiocy, etc. Such offspring are pale and puny and the 
victims of all morbid influences. 

Inherited Tendency to Apoplexy. 

1. The tendency to arterial degenerations, periarteritis, organic diseases 
and consequent cerebral hemorrhage, or apoplexy, is inherited in the same 
sense as tuberculosis, and is a prominent factor of causation. 



io6 The Life Insurance Examiner. 

2. This tendency may remain latent until the age when various exciting 
causes begin to act, say from forty to seventy, or even eighty, but it is apt 
to appear earlier in each succeeding generation. 

3. The so-called apoplectic constitution — the stout, thick-set build, with 
short neck and florid complexion — transmitted from one generation to 
another, is a myth, and has, per se, no bearing upon the etiology of the dis- 
ease, except it is associated with some causative organic disease or habits of 
excessive indulgence. 

4. This hemorrhagic tendency is increased by alcoholism, Bright's dis- 
ease of the kidneys, especially chronic interstitial nephritis, hypertrophy of 
the heart, aneurism, embolism, a life of constant cerebral excitement like 
that of a speculator, broker or gambler, etc. 

5. The constant use of alcoholic drinks in excess predisposes by induc- 
ing degeneration of tissues and low forms of inflammation of the small 
arteries ; and by causing dilatation of the vessels by paralyzing the vaso- 
motor nerves, which result in chronic congestion. 

6. The greater frequency of apoplexy among males arises from alco- 
holism. 

7. The applicant should be rejected if any symptoms suggest the prob- 
ability of an attack. 

8. He should be rejected also in case he has ever had any symptoms of 
an apoplectic seizure, no matter how complete his recovery seems to be. 

Paralysis. 

1. The tendency to general paralysis is often transmitted. 

2. Every case of previous hemiplegia or paraplegia rejects the applicant. 

3. Many cases of local palsy are entitled to insurance, provided the 
causes are local or capable of relief. 



NUTRITION AND DIATHESIS. 



CONSTITUTIONAL DISEASES 

AND 

DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS. 



H E following are the principal diseases classified under thL head, which 
will be considered briefly, and solely with reference to their bearing 
-L upon the rejection, postponement or acceptance of the applicant for 
insurance. 

It must be remembered, however, that the executive officers of each 
company, after receiving full information from their Medical Examiner, 
always exercise the right to pass final judgment on the risk, and their action 
is largely governed by their personal experience, so that the following rules 
must not be considered absolute. They are simply intended as guides 
toward a correct judgment. 

Rejections, Postponements and Acceptances. 

REJECTIONS. — The Medical Examiner's report to the home office should 
show clearly the grounds of rejection, or should be accompanied by a letter 
of full explanation, so that the executive officers may understanding^ 
ratify or modify his decision, and take the responsibility therefor. All col- 
lateral documents go on file with the application. 

Postponements. — All cases of postponement on account of physical 
disability require a certificate from the attending physician or surgeon after 
the completion of the cure, stating that the applicant is cured and free from 
prejudicial after-effects. Re-examination by the Medical Examiner should 
be required if the postponement continues for more than thirty days. 

ACCEPTANCES. — The applicant is entitled to acceptance at the hands of 
the company when no cause for rejection or postponement is found ; but 
the Examiner should give the company the benefit of any doubt for the 
protection of existing policyholders. 

The diseases that require notice in this chapter, seriatim, are consump- 
tion, scrofula or struma, cancer and tumors, sarcoma and other malignant 
tumors, gout, rheumatism, syphilis and chancroid, insanity, epilepsy and 
convulsions, alcoholism or intemperance, apoplexy, paralysis, established ex- 
treme leanness or obesity, fatty or atheromatous degenerations, dropsy, 
anaemia, plethora, purpura, leucocythsemia, lymphadenoma or Hodgkins' 



ic8 The Life Insurance Examiner. 



disease, indicated by a general enlargement of the lymphatic glands and 
spleen, with progressive anaemia, Addison's disease of the supra-renal cap- 
sules, and affections of the spleen. 

Consumption. 

This disease is so important from the life insurance point of view that 
we deem it necessary to review the leading facts of its etiology, pathology 
and symptoms. The diagnosis of this insidious disease in its stage of incu- 
bation will tax the highest powers of observation and comparison ; and this 
is the stage which usually claims the attention of the Insurance Examiner, 
before the applicant himself is aware of his condition or danger. The latter 
may thus unconsciously mislead the Examiner by his blind answers to ques- 
tions and by his entire ignorance of his own condition. 

The Examiner must depend for success in diagnosis upon a thorough 
knowledge of the literature of the subject ; experience in physical diag- 
nosis, so that he can readily detect the slightest variation from the normal 
standard of pulmonary health ; and a careful differentiation of the physical 
and subjective symptoms of the individual case under examination. 

Definition. — Consumption is "the collective expression for all the 
progressively destructive processes within the respiratory organs, or molec- 
ular death of the lung-substance, which do not occur successively and rap- 
idly in the train of acute pulmonary inflammation." 

Varieties and Synonyms. — (i.) "Catarrhal consumption," or 
" chronic catarrhal pneumonia." where the disease is a continuation of a 
catarrhal pneumonia. (2.) " Fibrosis," " cirrhosis," or " induration of the 
lung," where connective tissue over-growth is prominent. (3.) "Tubercu- 
lar," or " acute miliary tuberculosis," where miliary tubercle is deposited 
within the lymphatic structure of the lungs. 

MORBID ANATOMY. — The Catarrhal Form is characterized by a pre- 
vious catarrhal, or lobar pneumonia, which has not been followed by reso- 
lution during the third stage, but whose products have become caseous. 
This caseous matter creates ulceration of the lungs by acting as a foreign 
body, and, possibly, induces miliary tuberculosis by absorption. In rare 
cases this caseous matter may become encapsulated and innoxious. 

The Fibrous Form is manifested by (1) proliferation of new connective- 
tissue cells in the lung ; (2) organization of these cells and formation of 
new connective-tissue ; (3) contraction of this new connective-tissue, creat- 
ing pressure upon the vesicular structures. 

The Tubercular Form is produced by an absorption of caseous matter 
from some other part of the body, resulting in a lymphatic formation in the 
peri-vascular spaces of organs (especially of the lungs), which, under the 
microscope, shows giant-cells. The tubercular portions subsequently un- 
dergo ulceration and excavation (probably by the pressure exerted on the 
blood-vessels causing impairment of nutrition). 



The Life Insurance Examiner. 109 

PREDISPOSING CAUSES*. — Hereditary or acquired constitutional de- 
bility ; bad hygiene ; damp, cold climate ; badly drained or miasmatic soil. 

Exciting Causes. — Extension of a bronchial catarrh ; pneumonia ; 
subacute pleurisy or laryngitis ; inhalation of irritating particles or gases ; 
exposure to cold or sudden changes of temperature. 

RATIONAL Symptoms, in their order. — Incipient stage, constant ele- 
vation of temperature ; emaciation, steady and gradual ; loss of weight ; 
characteristic clearness of complexion ; flushing caused by exertion ; 
pearly conjunctivae ; dyspnoea, after exertion; accelerated respiration and 
pulse. 

Night-sweats, or ill-defined chills of the surface ; clubbing of the finger- 
nails; peculiar cough ; arrest of menstruation in females; increased sexual 
desire. Later symptoms : Steady cough ; expectoration often streaked 
with blood, indicating lobular consolidation ; haemoptysis ; pain in the 
chest, due to local pleurisy; indigestion; vomiting; partial aphonia, from 
ulceration of the larynx; hectic fever, when cavities are formed; cyanosis, 
when disease is extensive', diarrhoea, a bad symptom, due to indigestion, 
follicular ulceration of the intestines, etc. 

PHYSICAL SIGNS. — First Stage of Consolidation. — Inspection : Promi- 
nent clavicles, flatness of the chest, unequal height of shoulders, depression 
in the infra-clavicular spaces, diminished expansion of the chest, etc. Pal- 
pation : Vocal fremitus increased. Percussion : Slight dullness, on one or 
both sides. Auscultation : Respiration rude or blowing ; prolonged and high- 
pitched expiration (characteristic); rales, sub-crepitant, mucous, crepitant 
or metallic; intensified vocal resonance. These signs of the first stage are 
important, and comparison should be made between the two lungs. 

Second Stage of Softeni?ig. — Inspection : Diminished expansion of the 
chest ; respiration more frequent ; marked depression above and below the 
■clavicle. Palpation: Increased vocal fremitus. Percussion: Dullness in- 
creased (wooden). Auscultation : Bronchial breathing; abundant rales, cir- 
cumscribed and bubbling ; crackling sounds over certain areas. 

Third Stage of Excavation. — Inspection : Retraction of chest-walls. 
Percussion: Dull, amphoric, or cracked-pot. Auscultation: Cavernous 
and bronchial respiration and gurgles; ''cavernous whisper." 

Differential Diagnosis. — From all forms of bronchitis ; croupous 

*An advocate of the germ theory epitomises his views of this disease, as follows: "Con- 
sumption is immediately set up by the bacillus accidentally implanted. We all inhale or ingest the 
contagium because of its ubiquity, but the same will not proceed to phthisis unless the soil 
be favorable. Favorable soil particularly occurs when the subject is (i) lean, with a dyspepsia for 
fats ; (2) run-down or enfeebled from any cause ; (3) prone to respiratory catarrh ; (4) subjected to 
the breathing of confined and foul air. A tendency to that combination of innutrition and catarrhal 
habit that goes to make up a susceptibility to breed well the consumption-bacillus, is apt to run in 
families, and hence, and hence only, do we get the showings of a family obnoxiousness to phthisis. 
(Except where one member of a family nurses and sleeps with a consumptive, the disease may be lit 
up because of the overwhelming absorption of the contagium.)" 



no The Life Insurance Examiner. 



pneumonia, especially if at the apex of the lung or accompanying typhoid 
fever; pleurisy; pulmonary infarction, and haemoptysis. 

PROGNOSIS. — Catarrhal Form : In first stage may be arrested by change 
of climate and proper treatment. Fibrous Form : Prognosis good as regards 
duration of life under proper conditions; prognosis bad when complicated 
with laryngitis, pulmonary oedema, capillary bronchitis, pulmonary conges- 
tion or hemorrhage. 

Tubercular Form. — Prognosis is most unfavorable. 

Rejection. — The actual presence of consumption, even in its incipient 
stage, as indicated by the family and previous history of the applicant, com- 
bined with the subjective symptoms and physical signs, absolutely rejects 
the candidate. 

Inherited Taint. — The following conditions reject: (i.) The death of 
both parents, even at an earlier age than the present age of the applicant. 
With some companies the death of both parents rejects only during eariy 
and middle life, provided the person is of exceptionally robust physique 
and there were extenuating circumstances attending one or both cases of 
death. (2.) Three or more deaths in the immediate family, comprising a 
parent and two or more brothers or sisters older than the applicant, even 
though personal points favor. (3.) Two deaths of brothers or sisters older 
than the candidate, unless the individual conditions and environments are 
most desirable. (4.) When the applicant exhibits the tuberculous diathesis, 
although the family record shows no deaths from consumption. 

POSTPONEMENT. — (1.) Death of one parent, or of more than one of the 
brothers and sisters, ordinarily postpones the applicant, otherwise accept- 
able, until he has reached the age of thirty. (2.) When the infant mortal- 
ity in the family has been great, and the surviving members, including the 
applicant, are quite young, or he is the only survivor, he should be post- 
poned until the age of thirty, when the expectation of life may be more 
accurately calculated, unless the physique and health record are above the 
average. (3.) The death of a grandparent, or parent of the same sex, sug- 
gests that the taint may appear in the applicant under exciting causes, and 
necessitates postponement until age and favorable personal points shall 
decide the case, unless the applicant's physique and health record are above, 
the average. (4.) When the applicant resembles the tainted parent, though 
the disease is more commonly transmitted through the mother, postpone 
the risk as above, unless the physique and health record are above the aver- 
a § e - (5-) When both parents have died comparatively young, the one from 
consumption and the other from cancer, abscess, erysipelas, intemperance, 
heart, kidney or nervous disease, the applicant doubtless inherits the taint 
of one or both parents, and should be postponed as above, or rejected. 

Acceptance. — (1.) The single death of a brother or sister, when other 
points of family history and personal examination are favorable, should not 
prevent insurance. 



The Life Insurance Examiner. i i r 

(2.) When two deaths in a numerous family have occurred, the one of 
a parent over forty years of age, and the other of a brother or sister below 
the applicant's present age, if the examination presents no other objection- 
able features, there is no ground for rejection. 

(3.) The risk maybe accepted, after having been postponed for a period 
of from seven to ten years after a first attack of haemoptysis, provided the 
Examiner is satisfied of the continuous good health of the applicant in the 
interim. 

Scrofula or Struma. 

POSTPONEMENT of all cases associated with this diathesis or cachexia, 
such as bone or joint disease. Caries or necrosis, Potts' disease of spine, 
hip joint disease, etc., extensive glandular swellings, abscesses of any size, 
such as the psoas or lumbar variety, and open ulcers or skin diseases 
depending on defective nutrition or vice of constitution must imperatively 
be postponed by the Medical Examiner. At the completion of cure, after 
the lapse of a safe interval, he must procure the certificate of the attending 
surgeon, to file with the application, before any form of insurance policy 
can be issued to the applicant. 

Cancer and Tumors. 

REJECTION. — (1.) When cancer and tuberculosis coexist in the family 
history the applicant should be rejected. 

(2.) When two or more deaths have occurred in the family. 

(3.) When any constitutional or local symptoms are present. 

(4.) When there is a sarcoma or other malignant tumor. 

Postponement. — In cases of removal of benign tumors, six months 
after complete recovery from the operation, a surgeon's certificate as to the 
improbability of relapse and any evil after-effects is required and put on file 
with the application. 

Acceptance. — (1.) The death of one parent from cancer, other points 
being favorable, should not debar the applicant from some form of insurance. 

Gout. 

REJECTION. — (1.) The presence of chronic, recurrent gout, especially if 
it appears before the age of thirty-five, combined with an inherited 
tendency and improper personal habits, should always reject. (2.) When 
the inherited diathesis, though not manifested by typical attacks of gout, 
manifests itself by gouty degenerations in the heart, blood-vessels, kidneys 
or nervous system, causing organic disease, the risk should be rejected. 

POSTPONEMENT. — (1.) When both parents, or a parent and grand- 
parent, or an uncle and aunt, have had gout, the risk is hazardous, and 
should be postponed until the applicant is over thirty-five. 

(2.) In cases of inherited or acquired gout, some companies require a 



ii2 The Life Insurance Examiner. 

postponement of several years, during which period there must be entire 
immunity from the disease, correct personal habits, and favorable environ- 
ment and physique. 

ACCEPTANCE. — (i.) When one parent or grandparent has suffered from 
gout, the applicant himself having never had an attack, and being of good 
habits, if the physical examination be favorable, he is eligible for insur- 
ance. 

(2.) If the applicant has passed the age of thirty-five without showing 
any symptoms of the disease, and if his physique is unobjectionable, even 
though two ancestors exhibit a history of gout, he is entitled to insurance. 

Rheumatism. 

REJECTION. — (1.) Acute or chronic rheumatism, which is long con- 
tinued, recurrent, metastatic, hereditary, sciatic or syphilitic, in each case 
rejects. Owing to its recurring tendency under the ordinary exciting con- 
ditions, and to the fact that heart disease is a common sequel, the insur- 
ance company should always be given the benefit of the doubt. The 
unmistakable rheumatic diathesis and seizures are referred to above, and 
not other minor forms. 

Postponement. — (1.) It is customary to postpone the applicant with 
the inherited diathesis and history of repeated attacks for a period of seven 
years, or until that lapse of time has occurred since the last attack. (2.) One 
or more attacks, coupled with a family history of acute articular rheumatism, 
postpones the risk as above. (3.) One of the large companies places the 
minimum term of postponement at one year from the last attack of articular 
rheumatism. 

Acceptance. — (1.) If no attacks appear before thirty-five, and the 
applicant is acceptable in other respects, he is eligible. 

(2.) Muscular rheumatism and local rheumatic pains of a functional 
nature do not prevent acceptation of the risk. 

Syphilis and Chancroid. 

Rejection. — (1.) The actual presence of symptoms of secondary or 
tertiary syphilis, absolutely rejects the applicant. (2.) Some companies 
include any history, past or present, of tertiary or inherited syphilis. 

Postponement. — (1.) In secondary syphilis, not followed by tertiary 
symptoms, the minimum term of postponement (by one company) is five 
years after the last manifestation. 

(2.) All cases of hereditary or acquired syphilis should be postponed 
until the routine treatment has banished every trace of the disease for a 
term of years, to be proven by the attending physician's certificate. 

(3.) Chancroid. — In the case of this local disease, not followed by con- 
stitutional symptoms, the minimum term of postponement is six months, 



The Life Insurance Examiner. 113 



and a surgeon's certificate of complete recovery is required and put on file 
with the application in the home office. 

Acceptance. — When the force of the transmitted or acquired 
disease has been neutralized by proper treatment and a favorable environ- 
ment, so that the applicant presents no traces of the disease, if unobjection- 
able in other respects, he is eligible : but the Examiner's action should be 
governed by the rules of the company for whom he is acting. 

Insanity. 

REJECTION. — (Consult previous chapter on the " Transmission of 
Insanity," which explains hereditary influences, symptoms, etc.) (1.) Symp- 
toms of insanity, actually presented to the Examiner, even of the incipient 
or masked type, most difficult of detection, should always reject. (2.) 
When the applicant's family history, with reference to insanity or other 
cerebral disease, is poor, and his own physical condition is below par, he 
should be rejected. 

Postponement.— (1.) All cases with the inherited taint should be 
postponed until adult life, when the life expectation can be more safely 
determined. (2.) When one slight attack is on record, postponement is 
required for a term of years, after the expiration of which period a physi- 
cian's certificate to prove immunity from attacks in the interim must be 
furnished, which is put on file. 

ACCEPTANCE. — (1.) Incidental or temporary insanity, unaccompanied 
by inherited taint or cerebral diseases, need not always deprive the appli- 
cant of insurance, if no symptoms have presented themselves for ten years. 

Epilepsy and Convulsions. 

Rejection. — (See 'section on " Hereditary Influences.") Confirmed 
epilepsy should always reject the applicant, on account both of the general 
impairment of health and of the imminent danger of accident during con- 
vulsions. 

Postponement. — (1.) Even after a long period of immunity from 
attacks, as the risk is hazardous from the liability to recurrence. (2.) 
Recurrent convulsions, unassociated with the history of transmitted 
epilepsy, temporary in character and of excentric origin, should postpone 
until all tendency to recurrence has disappeared. 

Alcoholism or Intemperance. 

REJECTION. — (Refer to the subject of " Inherited Tendency.") (1.) 
History of delirium tremens always rejects. (2.) The habitual drunkard 
should be rejected. (3.) Those cases which show the inherited taint, in 
both their history and present physical condition and habits. (4.) Most of 
the large companies absolutely reject all persons having anything to do 
with the retailing of alcoholic drinks. The Examiner should satisfy him. 



ii4 The Life Insurance Examiner. 

self thoroughly whether the applicant keeps a hotel or place of business in 
which alcoholic drinks are sold over a bar, and should be governed in his 
rejections and acceptances by the rules of the company for whom he is 
examining. 

POSTPONEMENT. — (i.) Intemperance tic or occasional*, term 

of postponement according to the case. : > Reformed drunkards. (3.) 
All who exceed Anstie's daily allowance, equal to one and one-half ounces 
of absolute alcohol, should be postponed, and obliged to furnish satisfac- 
tory evidence of abstinence or temperance for a certain period of time. 

1 :CEPTANCE. — (1.) All who do not exceed the above daily allowance, 
and show no evil effects of stimulants upon the vital organs, may be 
insured. (2-] One great company accepts hotel-keepers, wholesale man- 
ufacturers and liquor dealers at one-half per cent extra premium rates. 

REJECTION. — :. Any history, past or present, of apoplexy, absolutely 
rejects. _. When any symptoms suggest the probability of an attack. 
The reader should consult the chapter on M Inherited Tendency to 

Apoplex 

Paralv 

REJECTION. — I.) The presence of paralysis of any considerable part of 
the body, such as hemiplegia, paraplegia or paralysis from apoplexy, degener- 
ations, softening, traumatic lesion or pressure of tumors, absolutely rejects. 
(2.) Also when conjoined with heart disease or the apoplectic diathesis ; the 
most scrupulous care is requisite to detect irremediable causes. (5.) When 
not clearly explicable by temporary causes, it rejects. 

POSTPONEMENT. — (1.) Local paralysis of certain parts depending on 
definite local ca- -ting in derangements of motion, such as Bell's 

palsy of the u portio dura "; aphonia ; the muscular neuroses of the extrem- 
ities from overwork in certain occupations, like '* writer's cramp ": " wrist 
drop," from lead poisoning ; traumatic local paralysis ; reflex paralysis from 
deficient innervation and weakness : hysterical paralysis, mimicking organic 
diseases like tabes dorsalis, etc., all require postponement for a certain time, 
until the certainty of diagnosis is established, or cure is effected by proper 
treatment. A certificate is required from the attending physician to attest 
the recovery of the applicant. (2.) Paralysis of sensation or of special 
sense must be observed, in like manner, and its causation differentiated 
from any disease that would cause rejection. Postponement is necessary in 
all of these cases. 

A ICEPTANCE is admissible in those cases where the cause of the paralysis 
is palpably local, such as paralysis resulting from the division of a nerve by 
a surgical operation or accident, pressure from a benign tumor, etc. The 
company, however, should always have the benefit of the doubt in every case. 



The Life Insurance Examiner. 115 

Leanness or Obesity. 

> Rejection. — Established, extreme leanness, or obesity, is sufficient 
ground for rejection by some companies, presaging, as either condition does, 
some organic disease, owing to abnormal nutritive changes. If the lean- 
ness was of rapid development, it may indicate grave constitutional disease, 
and in case of sudden obesity, fatty degenerations of the heart, liver or 
other vital organs may be found ; and either contingency should absolutely 
reject. 

POSTPONEMENT. — It is safer to postpone the majority of these extreme 
cases until proof of their eligibility in all other respects shall have overcome 
the prejudice against the risk. 

ACCEPTANCE. — When it is certain, from the history and examination, 
that either of these peculiar physiological conditions did not take place rap- 
idly, that it is rather a family and permanent trait than the expression of 
any tendency to disease, or result of the same, the risk may be accepted, 
provided all other conditions are favorable. 

Tissue Degenerations. 

Various tissues in the course of disease become replaced with other 
■formations less suited to the peformance of the original physiological and 
anatomical functions of the part. This transformation is called degenera- 
tion. Degenerations may occur by direct chemical metamorphosis, as of 
albuminous into fatty material ; by infiltration of the tissues with some new 
material, as in albuminoid degeneration ; and by substitution of a newly 
formed tissue, as in fibroid degeneration. It is closely allied to the process 
of atrophy, being caused by defective nutrition and becoming a part of pro- 
gressive wasting. The following are the principal varieties: 1. Albumin- 
oid, or granular or parenchymatous degeneration. 2. Fatty metamor- 
phosis, infiltration or degeneration. 3. Cheesy degeneration or caseation, 
4, Hyaline, fibrinous or croupous degeneration. 5. Mucous degeneration. 
6. Colloid. 7. Amyloid, waxy or lardaceous. 8. Calcification, ossification, 
'putrefaction or atheromatous degeneration. 9. Pigmentation. 

REJECTION. — Whenever any one of these degenerative changes is immi- 
nent or in progress, the rejection of the applicant is imperative. Fatty 
degeneration of the vital organs or atheromatous changes in the blood ves- 
sels are recognizable, the former from feeble circulation and general debil- 
ity, and the latter from the characteristic hardening of the arteries. 

Dropsy. 

Dropsy is the common term used to denote the transudation of fluid 
through the walls of the blood vessels into the cavities or tissues of the 
body. Exudation is the term used for this condition when it accompanies 
inflammation ; effusion, for the same process associated with non-in- 
flammatory affections. Dropsy of the various forms, ascites, . oedema, 



u6 The Life Insurance Examiner. 

anasarca, etc., is a symptom either of grave organic disease or of a local 
affection which may readily be removed. When present at the time of the 
examination, much discrimination is required to determine the cause. 

REJECTION. — When dropsy is a concomitant of organic disease of the 
kidneys, heart, liver, lungs or other organs ; of chronic peritonitis; or when 
any of the constitutional cachexias coexist with it, rejection should be the 
invariable rule. 

Postponement. — In all doubtful cases, postpone and require a physi- 
cian's certificate that the cause is removed. 

ACCEPTANCE. — In some instances it follows malaria, fevers, peritonitis, 
acute disease of some one of the organs, etc; and when satisfactory evi- 
dence presents itself that the condition is fully cured, insurance may be 
granted. 

AN/EMIA. 

Anaemia signifies impoverishment of the blood, both in quantity and 
quality, either from lack of blood-making power or from waste after the 
blood is formed, and consists of a deficiency of red corpuscles and albu- 
minous material. 

Causes. — (I.) An insufficient supply of blood from lack of food, indi- 
gestion, functional derangement of lymphatic and blood glands, bad hygi- 
enic surroundings, or from the influence of certain poisons, such as lead, mer- 
cury, narcotics, malaria, etc., or from heart disease, aneurism, etc. (2.) Ex- 
cessive depletion of the blood by hemorrhages, profuse catarrhal, suppura- 
tive or albuminous discharges, by rapid growth, frequent pregnancies, ex- 
cessive lactacion, over-exercise, fever or new growths. (3.) A combination 
of the above causes may exist, as in the chronic constitutional diseases, 
such as nephritis, consumption, syphilis, cancer, etc. 

Symptoms. — Although this affection is said to be most prevalent among 
girls and young women, it is common enough among all classes to deserve 
the attention of the Insurance Examiner, and often coexists with the strong 
physique and fatty diathesis. The general symptoms are pallor, weakness, 
feeble circulation, palpitation after exertion, cold extremities, often an 
anaemic heart murmur, poor appetite, indigestion, headache, mental and 
physical lassitude, etc. 

Rejection. — Extreme cases, such as those mentioned above, which 
accompany chronic constitutional diseases, and also that peculiar form 
called progressive pernicious anaemia, absolutely reject. 

POSTPONEMENT. — Anaemia produced by any of the causes in the first 
category, and, in fact, any case exhibiting marked symptoms, should be post- 
poned and referred to the family physician for treatment, with the recom- 
mendation to reapply for insurance after recovery is fully established. 

Acceptance. — In many instances when the anaemia is slight and of 
an idiopathic nature, the condition need not delay the issue of a policy. 



The Life Insurance Examiner. 117 



Plethora. 

> This affection is the opposite of anaemia, and not as frequent. Ple- 
thoric persons have a superabundance of red corpuscles in the blood, from 
either inherited or acquired causes, usually due in either event to high 
living and neglect of physical exercise. The general symptoms are 
florid complexion, prominent blood vessels, full, strong pulse and forcible 
cardiac action, excitable temperament, excess of urates in the urine, etc. 
Plethora renders the individual liable to acute inflammations, atheromatous 
degeneration of the arteries and consequent apoplexy. 

REJECTION. — It is advisable to reject all applicants of this plethoric 
habit who are over-weight, given to excesses in eating and drinking, who 
lead a life of excitement and pleasure, and neglect open-air exercises. 

POSTPONEMENT. — Postpone for a sufficient period that quota of ple- 
thoric applicants whose occupation, environment and pledges afford a 
warrant that due self-control will eventually prove sufficient to counter- 
balance this abnormal tendency. 

ACCEPTANCE. — It is not unsafe to accept those candidates of full habit, 
who are otherwise insurable, who are confirmed in habits of temperance at 
business, at the table and during the hours of recreation and exercise. 
They are likely to reach old age. 

Purpura. 

Purpura is the general term applied to circumscribed cutaneous hem- 
orrhages, occurring either with or without constitutional symptoms. It 
seems to depend on weakness in the walls of the smaller blood vessels, 
combined with excess of fluid and salts in the blood. 

REJECTION. — <fc Purpura hemorrhagica," which is accompanied sooner 
or later by dangerous internal hemorrhages and effusions of blood under- 
neath the mucous membranes, is always ground for rejection. 

Postponement. — "Purpura simplex" and " rheumatica " require 
postponement until complete recovery ensues. 

LeUCOCYTHyEMIA. 

REJECTION. — " Leukaemia " is another name for this affection, which 
consists of an enormous increase of the white corpuscular elements of the 
blood often equaling in number the red corpuscles, when the ratio should 
be one white, to 350 red, in a state of health. It is associated with disease 
of the spleen, lymphatic glands and medulla of bone ; and as it is eventually 
fatal, the rule of rejection must apply to all such cases. Microscopical 
examination of the blood will confirm the diagnosis. 

Hodgkin's Disease. 
REJECTION. — " Lymphadenoma," and " pseudo-leukaemia," are other 
synonyms for this disease, which resembles leucocythaemia, and is generally 



u8 The Life Insurance Examiner. 



fatal. There is a general enlargement of the lymphatic glands and spleen, 
with progressive anaemia, but the white-blood globules are not relatively 
increased. Rejection is imperative. 

Addison's Disease. 

REJECTION. — Addison's disease of the supra-renal capsules is a fibro- 
caseous degeneration, and proves fatal within two or three years at most. 
Symptoms : Marked anaemia, pearly conjunctivae, a peculiar bronzed discol- 
oration of the skin, most marked on the face, neck, arms and genital organs ; 
extreme weakness, feeble pulse, and gastro-intestinal disturbances. As a 
matter of course, the Examiner is not likely to encounter any of these grave 
diseases — except in the stage of invasion — but for that very reason he 
should be all the more on his guard against accepting them. 

Rejection is imperative. 

Diseases of the Spleen. 

Rejection. — True inflammation of the spleen is exceedingly rare. All 
enlargements of that organ associated with enlargements of lymphatic 
glands, leucocythaemia, Hodgkin's disease, cirrhosis of the liver, consump- 
tion, etc., increase the necessity for rejection, 

POSTPONEMENT. — Enlargements of the spleen dependent upon the 
malarial cachexia demand postponement. 

Skin Diseases. 

REJECTION. — Manifestations of inherited or tertiary syphilis, according 
to the rules of a leading company, totally reject. Cutaneous traces of 
any malignant disease also reject. 

POSTPONEMENT. — When there are symptoms of secondary syphilis, 
not followed by tertiary symptoms, the minimum term of postponement 
by one company is five years from the last manifestation ; for chancroid the 
minimum term is six months. Erysipelas, open ulcers, severe boils, 
abscesses, carbuncles, etc., and all grave skin eruptions postpone until a 
physician certifies in writing that the cause is removed and complete recov- 
ery has taken place. 

Acceptance. — Simple and non-diathetic affections of the skin do not 
prevent acceptance. 

Diseases of Special Sense. 

REJECTION. — Loss of sight or hearing from causes associated with or- 
ganic or nervous disease is ground for rejection. 

POSTPONEMENT. — Otorrhcea, or uncomplicated diseases of the eye, post- 
pone until complete cure is effected. 

ACCEPTANCE. — One company accepts cases of total, uncomplicated 
deafness or blindness, but charges one-half per cent extra premium. 



The Life Insurance Examiner. 119 

NFRVOUS DISEASES. 

> Diseases of the nervous system, at least in their acute or sub-acute 
stages, will seldom come under the observation of the Medical Examiner 
for life insurance. We shall, therefore, make no attempt to classify all of 
them ; but it is necessary to consider certain abnormal states of the cerebro- 
spinal system, as well as some chronic forms of nervous disease, which may 
engage his notice. It will be incumbent upon him to employ the laws of 
" exclusive diagnosis " in many of these perplexing cases, which will deter- 
mine whether rejection shall follow when they are traced back to an organic 
disease, or postponement and final acceptance, if they prove to be of a 
functional nature. 

Headache. 

Headache differs in location, degree of pain, causation, duration, etc. 
Varieties, according to causes, are : (i.) From cranial or structural causes, 
depending on diseases within the cranium. Headache arises from anaemia, 
congestion, thrombosis, or embolus of the cerebral capillary arteries, and as 
a symptom of impending cerebral apoplexy ; from inflammatory diseases, 
such as meningitis of all kinds, cerebritis, cerebral abscess and softening, 
caries and necrosis; from tumors of the brain and meninges; from cerebral 
concussion, etc. (2.) Reflex causes ; sick headache, " migraine," or " me- 
grim," from abnormal states of the stomach, liver, uterus, or from pregnancy. 
The pain in this variety is usually confined to one side of the head and is of a 
periodical nature. Constipation and excessive venery are other reflex 
causes. (3.) Blood causes; toxaemic headache. All the fevers and infec- 
tions, contagious diseases, blood-poisoning or degeneration, malaria, dia- 
thetic diseases, organic diseases, chemical poisons, alcohol, medicines, etc. 

Rejection. — Causes of the first class from intracranial organic disease 
necessitate rejection, as a rule, and the same is true of many incurable tox- 
aemic cases. 

POSTPONEMENT.— Reflex causes, when present at the examination, as 
well as those of the third, toxaemic class, require disqualification until the 
causes shall have been removed by appropriate treatment. 

ACCEPTANCE. — Mild forms of headache, functional in character and 
unassociated with any of the above serious causes, are unimportant in esti- 
mating the risk. 

Vertigo. 

Vertigo, or dizziness, is defined as the consciousness of a disordered 
state of equilibrium in the body, which ordinarily maintains its poise through 
the control of the sensory-motor centre in !:he cerebellum. Noises in the 
ears usually accompany the vertigo : Varieties : 1. Vaso-motor, due to local 
or general variations in the blood-pressure within the vessels, from vaso- 
motor influence ; in such diseases as sunstroke, anaemia, gout, etc. 2. From 
the effects of drugs like quinine, salicin, the salicylates, etc. 3. From ocu- 



i2o The Life Insurance Examiner. 

lar disorders, often mistaken for organic cerebral disease. Paralysis of any 
of the ocular muscles produces disorder of sight as regards external objects, 
and vertigo ensues. 4. Auditory or aural vertigo (Meniere's disease), 
caused by perversion or abeyance of the labyrinthine function of the ear. 
5. Gastric; caused by derangement or diseases of the stomach. 6. Nervous 
vertigo, accompanying nervous exhaustion or depression, from over-work or 
excessive indulgences. 7. The epileptic form, which precedes, or is asso- 
ciated with, an epileptic fit. 8. Migrainous vertigo, constituting one of the 
phenomena of sick headache. 9. Vertigo, due to organic disease of the 
nervous system. 10. Gouty vertigo, which appears with attacks of gout. 

REJECTION. — It is obvious that this disorder, when caused by incurable 
organic disease, must always be a cause of rejection. 

POSTPONEMENT. — Most of these causes of vertigo are amenable to 
treatment, and will not prevent acceptance at the expiration of a sufficient 
interval. 

Hysteria. 

Hysteria is the word employed to denote certain nervous phenomena 
resulting in convulsive seizures and alterations of functions in various organs, 
causing many perplexing symptoms and often simulating those which 
arise from real organic disease. In most cases these alarming manifesta- 
tions are immediately excited by the influence of some strong mental or 
emotional impression. 

REJECTION. — The Examiner should be careful to differentiate the 
symptoms of hysteria from those caused by structural, spinal or cerebral 
lesions, or incurable ovarian or uterine diseases, which render insurance out 
of the question. 

POSTPONEMENT. — Cases dependent upon curable ovarian or uterine 
complaints, require postponement. 

ACCEPTANCE. — Many applicants, in spite of marked symptoms of 
hysteria, are eligible for insurance, provided the examination fails to reveal 
evidence of actual disease and the person is in good general health. 

Derangements of Motion. 

The character of this manual makes it undesirable to attempt an ex- 
haustive classification and enumeration of nervous diseases. We give a 
simple account of those affections likely to be met with in the examining 
room, with their prominent causes, symptoms and rules for deciding the 
risk. The presence of abnormal nervous manifestations traceable to an 
organic lesion rejects the applicant; but these disturbances are often due 
to disorders of the digestive organs, to reflex influences eventually remov- 
able, in which event suitable postponement may allow of ultimate 
acceptance. 

Derangements of motion may be of either the voluntary or involuntary 
muscles. 



The Life Insurance Examiner. 121 



Tremors. 

REJECTION. — -Tremor, or tremulousness rejects : (1.) When the methods 
of exclusive diagnosis unmistakably refer these muscular agitations to cen- 
tral lesions. (2.) When it is associated with marked impairment of vitality 
or premature old age. (3.) When coexisting with evil habits, such as the 
use of opium, alcohol, etc., or with extreme metallic poisoning. 

POSTPONEMENT. — In case it is merely and obviously the result of indi- 
vidual idiosyncrasy or advancing age without other adverse features, or is 
due to reflex causes amenable to treatment, the applicant may be post- 
poned or accepted, according to the circumstances. 

Convulsions, Spasms or Fits. 

These morbid manifestations, including chorea, are not infrequent 
among males, as well as females, of an excitable nervous temperament. 

REJECTION. -Rejection applies to all cases due to central causes, such 
as brain disease, tumors or growths, hemorrhages, etc. 

POSTPONEMENT. — Cases due to excentric causes, such as dental, intes- 
tinal, uterine, or vesical reflex irritation, vitiated blood, retained excreta or 
chemical poisons, and the like, deserve postponement, or final acceptance, 
as the case may be. 

If these convulsive seizures of any kind have not recurred for several 
years, the risk may be good, especially if in the case of males the applicant 
has passed the age of twenty-five, or if females are over twenty-three, which 
periods mark the crisis of such a diathesis. 

(See under head of a Epilepsy and Convulsions," in the sections on 
" Hereditary Influences" and " Nutrition and Diathesis,". Part III.) 

Epilepsy. 
(See sections on " Hereditary Influences" and " Nutrition and Diat«he» 
sis," Part III.) 

Defective Co-ordination of Movements. 
(See " Epilepsy and Convulsions," in section on " Nutrition and Dia- 
thesis," Part III.) 

Chorea comes under this head, like the neuroses dependent upon cer- 
tain occupations, and should be judged according to the individual case. 

Rigidity of Muscles. 

REJECTION. — This affection is allied to paralysis and often betokens 
softening of the brain or other organic disease. 

Postponement. — When evidently due to local troubles which time 
and treatment may remove, delay in decision is recommended. 

Paralysis, 
(Consult " Paralysis " in sections on il Hereditary Influences " and 
" Nutrition and Diathesis," Part III.) 



i22 The Life Insurance Examiner. 



Derangements of Sensation. 

These morbid sensations are not as grave in import as paralysis of 
motion, and do not usually imply structural or inflammatory disease, 
being more related to the emotions. Pain is the leading derangement, 
often coexisting with a feeling of heat, cold, pressure, itching, tingling, etc. 

REJECTION. — Diminished sensation, or extensive anaesthesia, may indi- 
cate, more directly than derangements of motion, some central nerve lesion 
or the effects of poison. Exclusive diagnosis will alone establish this fact and 
determine rejection. The same may be said of disorders of the special senses. 

POSTPONEMENT. — If undoubtedly arising from local influences, blood 
poisons or diseases, skin diseases, etc., these derangements may prove 
nothing more serious than a temporary cause for postponement. 

Loss of Consciousness or Syncope. 

Syncope is a state of suspended consciousness due to sudden failure of 
heart action. Causes — (i.) Intrinsic cardiac conditions generally accom- 
panying organic heart disease, especially fatty degeneration. Other causes 
of this form of syncope are, pressure from tight articles of dress, excessive 
heat or sunstroke, lightning stroke, drugs like chloroform. (2.) Nervous 
syncope, due to sudden emotion, fear, grief, joy, concussion of the brain ; 
to reflex causes, from morbid conditions of the stomach or intestines, such as 
indigestion or worms ; from the liver, kidneys or uterus ; to painful injuries, 
or to spasm of the arteries from vaso-motor impressions. (3.) Blood 
causes, most commonly from hemorrhage, anaemia, or from serious consti- 
tutional diseases. (4.) Complex causes, which occur in cases of hunger and 
exhaustion ; railway accidents, where fear, pain, shock, injury and hemorrhage 
may combine to produce syncope; also a hot, impure atmosphere. Persons 
afflicted with the predisposing causes often lose consciousness from trifling 
exciting causes. 

Rejection, Postponement or Acceptance of a candidate with a 
history of syncope will depend upon its causes, as laid down above, present 
physical condition and prognosis of the individual case. 

DISEASES OF THE BRAIN. 

The commonest forms of diseases within the cranium, which may be 
presented to the Examiner, are chronic encephalitis, meningitis, growths or 
tumors, atrophy, hypertrophy or softening of the brain, chronic cerebral 
poisoning, insanity and apoplexy. 

Encephalitis. 

Rejection. — Encephalitis, or cerebritis, with meningitis in the acute 
and sub-acute stages, are diseases of the sick-room, but when chronic in charac- 
ter and causing slight general disturbance of health, they may be encountered 






The Life Insurance Examiner. 123 



by the Examiner. There may be a history of some injury to the head, or 
of disease tending to affect the brain ; some impairment of tne special senses ; 
abnormal pulse, hesitation in speech, headache, or general malaise, stiffen- 
ing of muscles, or some absurd mental manifestations; these symptoms 
should lead the Examiner to locate the cause accurately and reject the 
applicant. 

Cerebral Deposits, Growths or Tumors. 

REJECTION. — These conditions are often difficult of exact localization, 
but all that is required of the Examiner is to demonstrate their existence 
from the symptoms presented, from the history, diathesis and cachexia of 
the individual. Every case requires rejection. The ordinary symptoms 
are headache, nausea, mental disturbances, partial paralysis and epileptiform 
convulsions. 

Cerebral Atrophy. 

Rejection. — This affection is usually a disease of advancing age, but 
may occur earlier, and is caused by any condition that retards the supply 
of blood to the brain, such as the pressure from tumors, growths, embolism 
and ligation of arteries. It results in dementia. 

Cerebral Hypertrophy. 
Rejection. — This rare affection is occasionally noticed in young 
adults, and is usually associated with premature hardening of the bones of 
the cranium. These subjects have brittle bones, present a history of frac- 
tures and certain symptoms of cerebral disturbances. 

Softening of the Brain 

Rejection.— Chronic softening of the brain, or " ramollissement," is 
one of the most insidious diseases in its approach to that obvious phase, 
when no physician could mistake it. In the earlier stages, the Examiner is 
likely to be greatly perplexed by it. 

Causes. — It may be the sequel of acute inflammation or premature 
senility, mental shock, prolonged anxiety or over-work. It may also come 
on gradually as the result of local or general tissue degenerations, such as 
malnutrition, arteritis, embolism, deposits, fatty degeneration, etc. Symp- 
toms. — Though these are not infallible, some of the significant early symp- 
toms are headache, vertigo, impaired intelligence, memory and articulation ; 
nervousness, hypochondria, dullness of the special senses ; strange sensa- 
tions, pain or numbness in the limbs, local cramps or rigidity of certain 
muscles, feebleness of body and mind, decided change of the general tem- 
perament, and frequently constipation, nausea and vomiting, with diminished 
sensibility of the bladder. Sometimes there will be a: history of some 
accident or illness, from which the affection vaguely d?ces. The physiog- 
nomy of a typical case once seen will never be fr.rgotten. Methods of 
exclusive diagnosis should be employed to settle difficult points in each 



i24 The Life Insurance Examiner. 

case, and determine rejection. An analogous cerebral condition often 
follows complete sunstroke. 

Sunstroke, Insolation. 

Three varieties — (i.) Simple heat exhaustion; syncopal form, from 
failure of the heart's action. Death threatens from collapse and cardiac 
paralysis. (2) Asphyxial form, true sunstroke ; asphyxia and apncea ensu- 
ing from nervous shock following exposure to extreme heat, when the 
nervous system is prostrated from any cause, such as fatigue or dissipa- 
tion. (3.) The hyper-pyrexial form, intense fever from over-heating, 
paralysing the nerve-centres, and secondarily the vaso-motor nerves of the 
arteries. This form comes on night or day as a result of over-exercise, 
intemperance, weakness, or foul air, and the temperature of the body may 
exceed no° F. 

About fifty per cent of cases of the last two varieties die, the rest 
remaining more or less invalidated, or ultimately succumbing to nervous 
diseases superinduced by the insolation. 

REJECTION. — Any history of either of the latter forms of insolation, or 
symptoms presenting which point in that direction, should reject for pal- 
pable reasons. 

ACCEPTANCE. — History of the first form of syncopal insolation, if fully 
recovered from, is not a bar to insurance. 

Chronic Cerebral Poisoning. 

REJECTION. — This morbid organic condition often follows the habitual 
and excessive use of alcoholic and other nervous stimulants of all kinds: 
Opium, chloral, bromides, cocaine, "'hasheesh," tobacco, tea, coffee, etc. 
The victims of these baleful habits, though apparently in fair health, cannot 
endure any physical or mental strain, or bear to abstain from their indul- 
gences. Without showing any well-defined disease, they are wont to com- 
plain of mental and physical lassitude, suffer from insomnolence and are 
conscious of a general deterioration. They are suffering from chronic, 
poisonous changes going on within the minute tissues of the brain and ner- 
vous system, the symptoms of which are readily recognizable by the 
Examiner, and, on account of the uncertainty of reformation, they should 
in almost every instance reject the applicant. 

POSTPONEMENT is admissible in certain cases that seem to be on the safe 
side of the border line of this prevalent malady, and which promise wholly 
to remove the exciting causes. 

Neurasthenia. 

Neurasthenia is not to be accepted as a distinct affection, but should 
be regarded as a condition of bodily exhaustion, frequently associated with 
various chronic disorders and sometimes with perverted functions of the 
nerve-centres. 



The Life Insurance Examiner. 125 

Causes. — Former diseases, over-work, excessive mental emotions, inher- 
ited tendency, etc. The symptoms are general and local manifestations of 
nervous exhaustion. 

REJECTION is demanded when the applicant's condition is incurable. 

POSTPONEMENT is the rule when delay and proper treatment are likely 
to bring about an insurable state of health. 

Dipsomania, delirium tremens, intemperance, alcoholism — synonymous 
terms — insanity, apoplexy. (See former sections in Part III. on " Hered- 
itary Influences " and " Nutrition and Diathesis."^ 

DISEASES OF THE SPINAL CORD, 

Spinal Inflammation. 

Symptoms. — A fixed pain along the vertebral column, which is aggra- 
vated by movements of the body, local pressure and the application of heat. 
There may be spasms or paralysis of the muscles of the back, and fre- 
quently curvature of the spine. 

Rejection. — Rejection must follow chronic inflammation of the 
meninges or substance of the spinal cord. It must be distinguished from 
rheumatic and neuralgic conditions. 

Spinal Irritation. 

REJECTION is the safest course in all well-marked instances of spinal 
irritation, with its array of symptoms, involving nervous hyperesthesia and 
excitability, and remote disturbances of the digestive, thoracic and cerebral 
organs. 

Spinal Paralysis. 

Rejection, without exception. (See Part III., sections on ^Heredit- 
ary Influences " and " Nutrition and Diathesis.") 

Locomotor Ataxia. 
Rejection in all clearly defined cases. Progressive locomotor ataxia, or 
"tabes dorsalis," is due to sclerosis of the posterior columns of the spinal 
cord. It begins insidiously, progresses slowly, and is apt to puzzle the ob- 
server during the period of its onset. The initial symptoms are, seriatim: 
Wandering, brief, sharp pains in the lower extremities, associated with dis- 
turbances of vision, inequality of the pupils, and possibly paralysis of the 
third or sixth pair of nerves ; vertigo, with difficulty in maintaining the 
equilibrium from defective co-ordination, shown in the impaired gait and 
inability to stand or walk with the eyes closed ; the ground does not feel 
natural to the feet ; muscles are well nourished and respond to electricity, 
and the patient can kick vigorously ; feeling of a girdling cord about the 
waist ; mind unaffected ; loss of sexual power may be an early symptcmc 



126 The Life Insurance Examiner. 

Later symptoms : progressive loss of sight, hearing and articulation, 
atrophy of muscles, dropsy and swelling of joints. 

DISEASES OF THE RESPIRATORY ORGANS. 

(For methods of physical diagnosis in respiratory diseases, see Part II., 
" Examination of the Chest ; " also refer to Part I., " Insurance Formali- 
ties," and "Instructions to Medical Examiners.") 

Catarrh. 

Catarrhal inflammation of the mucous membrane of the respiratory 
passages, whether of the acute, sub-acute or chronic type, is sufficiently 
common in our variable climate to make it a subject of careful investigation 
by the Examiner. 

Varieties. — Acute (coryza), or chronic nasal catarrh ; morbid nasal 
growths connected with it ; pharyngitis ; tonsilitis or quinsy, chronic sore 
throat, throat ulcers, etc. 

REJECTION is safest whenever there is any evidence pointing to consti- 
tutional cachexia, or hereditary tendency to disease, accompanying a chronic 
catarrhal condition. 

Postponement. — Postpone every case when the catarrh is present 
and appears to be undermining the general health of the applicant, spread- 
ing to the mucous membranes of the lungs, or associated with morbid nasal 
growths, chronic sore throat, ulcers or tonsilitis. 

Acceptance. — Mild catarrhs of a local and functional character in a 
person of good history and physique do not debar. Always examine the 
throat in catarrhal cases with a tongue-spatula or laryngoscope. 

Chronic Sore Throat. 

Pharyngitis of the chronic form results in thickening of the mucous 
membrane above the tonsils and the formation of ulcers. It may be caused 
by disorders of the stomach with acid eructations, and keeps the patient 
constantly hacking and clearing the throat. It is common among clergy- 
men and sedentary people, who breathe bad air and disregard considera- 
tions of proper diet and exercise. 

Throat Ulcers. 

Chronic ulceration of the throat is of grave import and may be idio- 
pathic, syphilitic or tuberculous. Examine the parts carefully in all cases. 

REJECTION. — Reject all cases of chronic sore throat or ulceration 
which point to scrofulous, consumptive, syphilitic, or other vice of con- 
stitution. 

Postponement. — Postpone all doubtful and idiopathic cases until the 
diagnosis or cure is established. 



The Life Insurance Examiner. 127 



Morbid Nasal Growths. 

POSTPONEMENT. — These cases should be postponed until, by removal 
of the growth or by the progress of the disease, it can be correctly deter- 
mined whether the applicant should be rejected or not. If accepted finally, 
the Examiner must be satisfied that the growth is non-malignant and non- 
recurrent. 

Tonsillitis or Quinsy. 

POSTPONEMENT. — The gravity of this affection depends on the fre- 
quency with which it is the concomitant of the tuberculous diathesis or 
general debility. The case should be postponed until its nature is demon- 
strated. 

ACCEPTANCE. — Mild cases of the non-ulcerative variety, which do not 
recur with frequency or deteriorate the general health, may be accepted. 

Diphtheria. 
Diphtheria, like scarlet and other fevers, is not likely to be seen by the 
Insurance Examiner, but its serious sequelae must be searched for in the 
person of any applicant who has had the disease. There are various forms 
of paralysis, albuminuria, dropsy, the tuberculous diathesis, etc., the pres- 
ence of which, as after-effects of diphtheria, is sufficient ground for rejection. 

Diseases of the Larynx. 
POSTPONEMENT. — These comprise the various neuroses, perversions of 
sensation, disorders of motion, paralysis and paresis of the muscles and of 
the vocal cords, and demand postponement. 

Aphonia. 
Causes. — Neurosis and nervous disorders of the larynx, such as 
hysteria or hypochondria ; organic disease of nerve centres ; paralysis of 
muscles from abuse of the voice ; new growths ; poisonous influences of 
drugs like lead, belladonna, stramonium ; mechanical causes; rheumatism; 
aneurism ; consumption ; syphilis, etc. Presence of the graver causes is 
ground for rejection ; of the others for postponement. 

Chronic Laryngitis. 
Postpone all cases that seem to be idiopathic. 

Reject all obstinate cases which have undermined the health and sug- 
gest a scrofulous, consumptive, syphilitic or malignant cause. 

DISEASES OF THE BRONCHI AND LUNGS. 

Acute Diseases. 

POSTPONE in every instance. Re-examination will demonstrate if any 
lesions are left behind. 

(Review the sounds of normal respiration and the contour of the thorax 



The Life Insurance Exam:: 



Part II.. • Examination of the Chest," and notice any departure from the 
standard.) 

Pain in zy.z Thorax. 
Causes. — Affecting the respiratory organs. /;; tlu Lung. — Bronchitis, 
pneumonia, cancer, a: r'arction, phthisis, obstructions in the bronchi. 

In tlie Pleura. — Pleurisy, pneumo-thorax, haemo-thorax, cancer. In ti. 
diastinum. — Tumors, diaphragmatic hernia. Affecting the heart and 

pericarditis, pneumopericardium, haemo-pericardium, cancer, 
myocarditis, ulcerative endocarditis, angina pectoris, cardiac neuralgia. 
Affecting the walls of thorax. Surgical Conditions. — Contusions, trauma- 
tisms, fracture of the ribs or of the vertebrae. Diseased Conditions. — Inter- 
J neuralgia, muscular rheumatisn: scess . cancer or tumors of thoracic 
stricture of the oesophagus. >:al Causes. — Dyspepsia; pre 

rd by any organ. (From I .nual of Medici: - 

Col 

L — Cough is a spasmodic, expiratory effort, associated with a 

contraction of the diaphragm, by which nature endeavors to remove some 
source of irritation, or expel some abnormal substance from the respiratory 
tract. Vi — According to origin, it may be laryngeal, tracheal, 

bronchial or nervous and sympathetic. According to the amount of 
expectoration, it is dry or moist, etc. A dry cough is said to be irritating, 
nervous, sympathetic, tight, hollow, barking, brazen, hacking, tickling, 
short, sharp, hoarse, shrill, whistling, stridulent. paroxysmal, whooping, 
distressing, etc., and expectoration is usually absent 01 The moist 

cough is termed loose, deep, soft, paroxysmal, labored, prolonged. 

s the case maybe. Various A~ — A dry cough indicates 

irritation, and is heard early in affections of the uvula, phai 
trachea, in bronchitis and pleurisy . sometimes it is caused by affections of 
the livei stomach, intestines, uterus or brain, by dentition, presence of 
worms, or diseases of the circulator}- organs, again.it may be ner 
Most sympathetic coughs are dry. Cov _ id to be dry, hollow and 

hacking in nervous and sympathetic affections ; tight, 

stridulent g, in affections of the larynx and trachea 

brazen in hysteria ; dry and tight in e : nchitis ; barking in incipient 

phthisis ; short and sharp in pneumonia and emp. ing and 

hoarse in early or spasmodic croup stling in advanced membranous 

croup • paroxysmal and whooping in \ is ; paroxysmal in asthma, and 

often so in laryngeal affections at scess of the lung and consumption. The 
moist cough rarely occurs ex:er: in diseases of the respiratory organs, and 
depends upon the presence of secretions in the bronchial tubes or longs. 
It is soft, deep and loose in advanced bronchitis with free secretion in 
cedema of the lung and last stage of pneumonia; deep and distressing in 



The Ltfe Insurance Examiner. 129 

chronic phthisis. It is generally associated with profuse expectoration, 
wh;ch varies in appearance according to the disease. 

Cough is often increased or diminished by changes in position; the 
recumbent posture generally intensifies it. 

REJECTION — Habitual coughs caused by any chronic and incurable 
disease of the organs of respiration should reject 

POSTPONEMENT.— Postpone all doubtful cases of habitual cough until 
the diagnosis or cure is settled If the habitual cough is merely reflex or 
functional, and not connected with any chronic or incurable disease of the 
air passages, it should not debar the applicant from insurance. 

DlSPNGEA. 

Definition. — Dispncea means difficult breathing or habitual shortness 
of breath, and is the term commonly used to denote any disorder of respir* 
ation. 

Varieties. — (1.) Deficient respiration; e. g, slow, restrained, shallow 
and ineffectual breathing. (2.) Dispncea ; obstructive breathing, excessive 
breathing or ordinary dispncea, shortness of breath, expiratory dispncea, 
orthopncea (which indicates that the patient can only breathe comfortably 
in a sitting posture), paroxysmal dispncea. (3.) Peculiar disorders; e, g. y 
breathing peculiar to certain nervous complaints ; the interrupted, jerky, 
sighing or yawning respiration ; Cheyne-Stokes respiration of cerebral 
hemorrhage, heart disease, especially fatty degeneration, and injury to the 
brain ; this is characterized by breathing which becomes more and more 
rapid and deep up to a certain point, then gradually decreases and finally 
pauses for an intervaL 

Causes. — (Moir's Manual.) Dispncea is due to some mechanical inter- 
ference with the free entrance of air to the lung. Causes above the Larynx. 
— May result from pressure on the facial nerve, from obstruction in the 
nares, suppurative, tonsillitis, retro-pharyngeal abscess, cancer or other 
tumor of the mouth or pharynx, or foreign bodies in the pharynx. Causes 
in the Larynx. — Laryngitis, various forms — oedema glottidis, laryngismus 
stridulus, laryngeal tumors and paralysis, pressure upon, or foreign bodies 
in, the larynx. 

Causes in the Bronchi. — Bronchitis, various forms, asthma, foreign bodies, 
hemorrhage, pressure and dilatation. Conditions of the Lungs. — Emphysema, 
pneumonia, phthisis, oedema, congestion, infarction, apoplexy, abscess, 
cancer, gangrene, atelectasis, compression. Conditions of the Pleura. — 
Pleurisy ; acute, subacute and chronic or empyema, pleuritic adhesions, 
hydro-thorax, pneumo-thorax, hydro-pneumo-thorax, hoemo-thorax, cancer. 

Conditions of the Heart. — Pressure on the heart, enfeebled action, mitral 
disease, rupture of valves, angina pectoris, cardiac dilatations, fatty heart, 
myocarditis, endocarditis, ulcerative form chiefly, accelerated action. Con- 
ditions of the Pericardium. — Pericarditis with effusion, adhesions, pneumo, 
hydro, haemo-pericardium, cancer, pus in the pericardium. Conditions of the 



130 The Life Insurance Examiner. 

Large Vessels. — Aneurism of the arch of the aorta by pressure on the lung. 
Aneurism of the pericardial sac by pressure on the heart, air in the veins. 
Conditions of Air Respired. — Deficiency of oxygen, too high altitudes, dele- 
terious substances and impure air. Conditions of Blood. — Anaemia, chlorosis, 
poisons. Conditions of the Nervous System. — Diseases of the brain, of the 
upper part of the spinal cord, injury or pressure on the following nerves: 
Pneumo-gastric, phrenic, spinal accessory, laryngeal or cardiac; exhaustion, 
tetanus, hydrophobia. Conditions Affecting the Parietes or Muscles of the 
Chest. — Spasm of the muscles, all painful affections of the external struc- 
tures, paralysis of the respiratory muscles, wounds or contusions of the 
soft parts, ossified cartilages, fracture of the ribs, dislocation or fracture of 
the spine. Conditions Affecting the Diaphragm. — Enlarged organs, preg- 
nancy, tympanites, ascites, peritonitis, brain disease and tumors. 

Rejection. — Reject when the dispnoea is marked, permanent or due to 
uninsurable conditions. 

POSTPONEMENT. — Postpone all cases, thus reserving an opportunity to 
re-examine the applicant and determine whether the dispncea is nervous or 
a harmless idiosyncrasy. 

Chri >nic Bronchitis. 

Definition. — Chronic bronchia's is alow grade of catarrhal inflammation, 
tending to recur with increased severity and duration until it becomes per- 
manent. The croupous form is still more serious. It may be limited to 
the larger tubes or extend to the capillary air vessels. 

Causes, Predisposing. — Exposure to cold or wet, bad air, repeated acute 
attacks, constitutional diseases, such as gout, etc., and organic diseases. Excit- 
ingCauscs. — Irritation from substances inhaled, mitral stenosis, chronic alco- 
holism. Symptoms. — Early stage — cough, expectoration muco-purulent, 
increasing in winter, decreasing in summer, finally becoming permanent. 
Later stage — violent cough, expectoration more offensive, soreness behind 
the sternum, dispncea, fever, night sweats and emaciation. Physical 
Signs. — Inspection — respiration accelerated or labored. Palpation — vocal 
fremitus may be normal or abnormal. Percussion — normal or temporary 
dullness. Auscultation — vesicular murmurs deficient, respiratory sound 
harsh, expiration prolonged, large or small mucous rales, changed in char- 
acter and position by the act of coughing or a full inspiration. Vocal re- 
sonance changeable. Differential Diagnosis. — From pleuritic effusions and 
consolidations of pneumonia or phthisis. 

REJECTION. — Reject all cases traceable to constitutional or organic 
diseases, or complicated by the same ; also when caused by any deleterious 
occupation, such as stone-cutting, needle-grinding, glass-blowing, or cotton- 
spinning. 

POSTPONEMENT. — Recurring or chronic bronchitis, even when uncom- 



The Life Insurance Examiner. 131 

plicated, because it materially impairs the expectation of life, should in all 
cases postpone the applicant. 

Asthma. 

Definition. — Asthma is a neurosis, which produces spasm of the invol- 
untary muscular fibres of the bronchial tubes and consequent paroxysms of 
dispncea. The symptoms are unmistakable— wheezing respiration, sibilant 
rales, etc. 

REJECTION. — Long-continued attacks of asthma tend to overwork and 
strain certain organs, and when it unquestionably coexists with dilatation of 
the bronchial tubes, emphysema, pulmonary congestion or oedema, haemop- 
tysis, tuberculosis, hypertrophy and dilatation of the right side of the 
heart, thoracic tumors, aneurism, obstructed circulation or disease of the 
liver or kidneys, organic disease of the brain or spinal cord, etc., rejection 
is peremptory. And the same is advisable when hereditary predisposition 
is marked. 

Postponement. — When the causes of asthma are clearly excito-motor, 
nervous and reflex, such as mechanical and local irritants to the respiratory 
surfaces, depending on individual idiosyncrasy or climate ; malaria ; portal 
congestion ; alcoholic stimulants ; disorders of certain organs ; nervous and 
emotional influences, etc., postpone until it can be demonstrated that the 
applicant can and will abate any of those conditions by removal of the 
cause, whatever it may be, so that his general health is not likely to be im- 
paired thereby in the future. 

Acceptance. — It must be borne in mind that most asthmatics who 
have no. serious complications, enjoy fully an average expectation of life 
from the fact that they are compelled to lead a careful, hygienic life. But 
even if the Examiner is possessed of obvious evidence of such compensatory 
habits on the part of the applicant, the latter should not be accepted unless 
there is absolute freedom from all symptoms of the condition and no prob- 
ability exists of a recurrence. 

Congestion. 

Postponement. — Any acute or chronic congestion of the respiratory 
tract, necessitates postponement and subsequent re-examination. In this 
way we can safely determine whether certain departures from the normal 
standard of pulmonary health are functional and transitory, or due to 
tuberculous deposits. 

Emphysema. 

Definition. — (1.) Vesicular emphysema is the term used to express 
abnormal distension of the air vesicles of the lungs, the pressure obliterat- 
ing some of the capillary blood vessels, interfering with the general circula- 
tion and mechanically straining the right side of the heart. (2.) It is called 
interlobular or interstitial when the vesicles have ruptured and allowed 
the air to infiltrate the areolar tissue between the lobules of the lung. 



152 The Life Insurance Examiner. 

Causes. — The principal cause is mechanical over-distension of the air- 
cells, either by forced inspiration or expiration, thus paralyzing the con- 
tractility of the air cells, and finally rupturing them. This may take place 
during the coughing paroxysms of chronic bronchitis, asthma, etc.; also 
from pressure of tumors upon the bronchial tubes ; from organic disease of 
the heart, playing on wind instruments, over-exercise, as in running ; remain- 
ing too long under water, as in partial drowning ; from any hereditary or 
acquired impairment of elasticity of the lung tissue. Emphysema may be 
compensatory or secondary around small portions of the lung, which have 
been rendered inexpansible from disease. It is called vicarious when 
emphysema of the healthy lung is produced around large areas of con- 
solidation or parts impaired by disease, as in atelectasis, from obstruction 
of a small bronchus, a lobar pneumonia or pulmonary infarction. 

Symptoms. — Constant dispncea, increased by exercise, coughing, or a 
cold climate ; dusky countenance, distension of the nostrils and veins of 
the neck ; feeble voice and pulse, weakness, emaciation, exhausting cough. 
Physical Signs. — Barrel-shaped chest, rising and falling movement during 
respiration, lack of expansion, displacement of the apex-beat, abdominal 
breathing. Vesiculotympanitic percussion notes ; prolonged, low-pitched 
expiratory sound, from loss of elasticity of the lung tissue, with feeble 
inspiratory sound. Complicatiotis. — Heart disease, chiefly of the right side, 
bronchitis, asthma, fatty degeneration of organs, disease of the kidneys or 
liver from obstruction of the general circulation. Differential diagnosis, 
from pneumo-thorax. 

REJECTION is demanded in every case of marked emphysema, owing 
to the impairment of vital capacity which it entails by interfering with the 
aeration of the blood, and rendering the system more liable to intercurrent 
diseases and serious complications. 

Pleurodynia and Intercostal Neuralgia. 

Pleurodynia is a rheumatic affection of the intercostal muscles, accom- 
panied by sharp pain, which is increased by the respiratory movements. 
Intercostal neuralgia appears in paroxysms of pain, periodically, which is 
not increased by movement. 

Acceptance. — Simple and uncomplicated forms of these complaints 
do not reject, in the absence of physical signs pointing to pulmonary, 
pleuritic or organic diseases, but all cases should be postponed until the 
applicant is free from the symptoms. 

Tumors Within the Chest. 

Intra-thoracic tumors may be steatomatous, fatty, fibrous, cancerous or 

aneurismal, and are always likely to produce pressure upon the lungs, heart, 

blood vessels or nerves, causing pain, shortness of breath, palpitation and 

displacement of organs, bulging of the ribs and sternum diminished reson- 



The Life Insurance Examiner. 133 

ance and vesicular murmur, deep-seated dullness. The exclusive method 
of diagnosis should be used to determine the absence of other lesions 
which might present the same symptoms. 

REJECTION is required in all cases, without exception. 

Deposits Within the Lungs. 

These deposits may result from inflammation, tuberculosis, cancer, 
melanosis, typhoid fever and syphilis. 

(1.) Inflammatory deposits in the parenchyma of the lung are detected 
by the physical signs and by historical and present symptoms. The exuda- 
tion of acute pneumonia may remain consolidated for a long time, or, in 
fact, permanently unabsorbed, even after the patient has regained apparent 
health. Physical signs are some retraction of the chest wall, restricted 
movement of the ribs in respiration, a dull percussion note, with bronchial 
respiration and broncophony over the site of deposit, and there may be 
dyspepsia and exacerbations of fever. 

Postponement. — The presence of this form of deposit postpones until 
re-examination demonstrates its disappearance or identifies it with the 
tuberculous variety, which is determined by the family history, diathesis, 
cachexia and course of the disease, and which, as a matter of course, rejects. 
Inflammatory deposit at the apex of the lung is exceedingly apt to undergo 
tuberculous degeneration. 

(2.) Tuberculous deposits must be recognized in their incipiency by 
the Medical Examiner, 

Rejection. — (Refer to article on consumption in section on "Nutri- 
tion and Diathesis,'' Part III., and article on 4 ' Hereditary Transmission," 
Part III.) (1 ) Hereditary taint, as described, rejects. (2.) Also a marked 
diathesis, even without local tuberculous deposits. (3.) Evidences of de- 
posit at the apices of the lungs, which are more liable to infection, owing to 
the fact that those parts are less used in ordinary respiration. Physical signs 
should be searched for carefully, particularly in the supra and infra-clavi- 
cular and supra-scapular regions, any variation from the normal standard of 
respiration being considered sufficient ground, at least, for postponement 
and re-examination. 

(3.) Typhoid deposits, yielding the same symptoms and physical signs 
as tubercle, may, nevertheless, become permanently reabsorbed and the 
patient regain perfect health. 

Postponement is in order in all these cases. 

(4.) Syphilitic deposits, under appropriate treatment for a term of 
years, may disappear and leave the patient in good health. 

REJECTION is imperative whenever their presence is demonstrated. 

(5.) Cancerous deposits absolutely reject. 

(6.) Melanoid deposits also reject the applicant. 



134 The Life Insurance Examiner. 

Cancer of the Lungs. 

REJECTION invariable. Varieties. — Medullar}* as a rule; melanotic in 
rare cases. It is commonly unilateral, or it may be diffused in nodules in 
both lungs. Primary cancer only affects one lung, but the secondary form 
usually appears in both lungs. Causes. — Hereditary tendency : cancer of the 
breast in females ; previous disease and injuries. The disease is most com- 
mon in men between forty and sixty years of age. Symptoms. — Pain in the 
chest, cough, currant-juice sputa, hemorrhage, etc.; enlargement or retrac- 
tion of the affected side, dullness, feeble respiration, bronchial breathing, 
etc. From consumption it is differentiated by slower progress, less consti- 
tutional disturbance, limitation to a single lung, history, presence of the 
cachexia from chronic pleurisy, which it resembles by the methods of 
exclusive diagnosis. 

Syphilis of the Lungs. 

REJECTION. — When present, syphilitic deposits in the lungs always 
reject. They closely resemble tubercles, which often become engrafted 
upon syphilitic degeneration of lung tissue. 

Chronic Pneumonia. 

Synonyms. — Fibrous or interstitial pneumonia; pulmonary cirrhosis. 

Definition. — It is the form of pneumonia which is associated with 
inflammatory deposits or connective tissue growths, which organize and 
contract. 

Causes. — Acute pneumonia, splenization, encapsulated abscess or infarc- 
tions. Symptoms. — Shortness of breath, pain, cough, with or without sputa, 
dullness of percussion sound, bronchial respiration, broncophony, increased 
vocal fremitus and resonance over the affected side, etc. 

Rejection follows in all cases where the deposit is not absorbed and 
there remains a suspicion of tuberculous taint. 

Chronic Pleurisy. 

Definition. — This is a subacute inflammation, with effusion of a sero- 
fibrinous fluid into the pleural cavity. Causes. — Primary form, from expos- 
ure to cold or dampness, injury. The secondary form may be due to, or 
follow any of the fevers, rheumatism, Bright's disease, pyaemia, septicaemia, 
alcoholism, pneumonia, cancer of the lung, phthisis. Symptoms. — Sense of 
fullness in the side or pain, dispncea on exertion, fever, loss of flesh, anxious 
countenance, enlargement of the affected side, displacement of the heart, 
absence of vocal fremitus, flatness below the level of the fluid, absence of 
respiratory murmur below the level of the fluid and bronchial breathing 
above ; pleuritic friction sounds as absorption takes place and the thickened 
pleural surfaces rub together during respiration. 

REJECTION. — It becomes necessary- to reject the applicant suffering 
from chronic pleurisy, whenever any incurable complication is present, or 
the disease seems to be progressing towards empyema. 



The Life Insurance Examiner. 135 

POSTPONEMENT. — Defer all uncomplicated cases until a re-examination 
shall decide the future eligibility of the candidate. The simple form of in- 
flammation may subside and leave few marks of deterioration, either in the 
chest or in the constitution. 

Pleuritic Adhesions. 

POSTPONEMENT and re-examination should be the rule in these cases, 
in order to determine the absence of any uninsurable organic disease. 
Simple forms of pleuritic adhesions which do not materially impair the 
breathing capacity, should not deprive the applicant of the benefits of life 
insurance, but all cases should be postponed at least one year after the 
attack. 

Empyema. 

When pus accumulates in the pleural cavity, the disease is called empy- 
ema. Both sides are usually affected, and it generally follows chronic dis- 
ease of the heart, liver or kidneys, and is associated with dropsy elsewhere. 

Rejection in every case must be the decision. 

Hydrothorax. 
Rejection. — This term signifies a dropsical accumulation within the 
pleural cavities, which is caused by organic disease of the heart, liver or 
kidneys, and coexists with dropsies in other localities. It invariably rejects. 

Hydro-pneumothorax. 
Rejection. — This is a condition characterized by the presence of both 
fluid and air in the pleural cavity and, of course, rejects. 

Collapse of the Lungs. 
REJECTION. — This disease begins with imperfect expansion of the air 
cells, which finally become shrunken over a considerable area, refuse to per- 
form their function, and at last constitute the condition called collapse of the 
lungs. It is caused either by bronchitis or compression. Physical signs 
are dullness, bronchial breathing and increased vocal fremitus. As it is 
likely to cause incurable lesions, it always rejects. 

HAEMOPTYSIS. 
Spitting of blood from the lungs, or haemoptysis. Causes. — (1.) Those 
situated outside the lungs, with which it may be confounded. It may come 
from the posterior nares, fauces, mouth, oesophagus or stomach ; from dis- 
eases of the larynx, trachea and bronchi (such as congestion, inflammation, 
ulceration, cancer, etc.). (2.) Causes in the lung — Mechanical hyperemia, 
from the inhalation of irritants, or too high altitudes. Traumatism, pul- 
monary congestion, pneumonia, acute or chronic ; abscess, gangrene, apo- 
plexy, phthisis, cancer, weak capillaries, aneurism of the pulmonary capillaries, 
etc. (3.) Mediastinal causes — Tumors pressing on the pulmonary vessels. 



136 The Life Insurance Examiner. 

(4.) Circulatory causes — Aneurism of the arch of the aorta bursting into a 
bronchial tube, mitral disease of the heart, hypertrophy of the right ventri- 
cle, dilatation of the left ventricle, diseases of the pulmonary vessels, such 
as aneurism of the pulmonary artery, aneurism of the arteria innominata, or 
of the carotid or subclavian artery opening into the air passages. (5.) Ner- 
vous causes — Vicarious menstruation. (6.) Blood causes — Hemorrhagic 
diathesis, scurvy, purpura. (7.) Other causes — Violent exercise or over- 
exertion, excessive use of alcoholic stimulants, habitual inhalation of 
tobacco smoke, such as is practiced by cigarette smokers, gout, rheuma- 
tism, blows on the chest, etc. 

REJECTION is imperative in every case that presents a clear history of 
spitting of blood from the lungs, either with or without the concomitance 
of suspicious symptoms of lung lesions, a history of inherited transmission, 
or the presence of the diathesis or cachexia. 

POSTPONEMENT. — Many companies postpone a case of haemoptysis for 
from seven to ten years after the attack, require a physician's certificate at 
the expiration of that period that there has been no recurrence, and a satis, 
factory re-examination from their own Medical Examiner, before they will 
issue any form of insurance policy. 

ACCEPTANCE. — If it is incontestably and positively proven by testi- 
mony that an alleged hemorrhage came from a harmless local source out- 
side of the lungs, and the medical examination is satisfactory to the Exec- 
utive Officers, a policy may be issued, but the benefit of any doubt should 
always be given to the company. 

Consumption. 

Rejection is the invariable rule when the disease is present. 

(The reader is referred for the full discussion of this subject to the sec 
tions on " Hereditary Influences " and " Nutrition and Diathesis," Part III., 
and to " Instructions to Medical Examiners," Part I.) 

DISEASES OF THE HEART AND BLOOD VESSELS. 

(Refer to " Examination of the Heart," Part II., for full data concern- 
ing the location of the heart, impulse, rhythm, position of valves, heart 
sounds and murmurs, observed by means of inspection, palpation, percus- 
sion and auscultation.) 

We proceed with a brief description of those diseases of the circulatory 
organs with which the life insurance examiner has to deal. 

Rejection. — Any organic disease of the heart or arteries positively 
rejects. 

Endocarditis. 

Definition. — Endocarditis begins with an acute inflammation of the 
serous membrane lining the cavities of the heart, which gradually becomes 
chronic and parenchymatous, resulting in thickening and induration of the 



The Life Insurance Examiner. 137 

endocardium. Most of the morbid changes are found in that portion of 
the membrane covering the valves of the left heart and lining the apex of 
the left ventricle. 

Pathology. — Thickening takes place from the increase of connective 
tissue. Retraction results from fibroid changes in the new connective 
tissue formations, causing puckering of the valves and giving their edges a 
cartilaginous consistence. Adhesions occur between the edges of the 
valves, producing, in some cases, a mere button-hole slit, most common at 
the mitral and aortic orifices. Degenerations of the valves ensue at a cer- 
tain stage of the disease, which are either fatty, granular or calcareous, and 
may end in ulceration, destruction of tissue, rupture of valves and regurgi- 
tation. Calcareous degeneration is more frequent at the aortic orifice and 
takes place late in life. Vegetations of a fibroid character grow upon the 
valves, which frequently cause sudden and fatal regurgitation, or, becoming 
separated from their roots, enter the circulation and give rise to embolism 
or develop infarction in some of the vital organs. All of these abnormal 
changes are due to the inflammatory process. 

Symptoms. — The chief manifestations of endocarditis are found in the 
alterations of the heart sounds, which indicate the various valvular lesions. 

Causes. — Morbid changes in the blood, which irritate and inflame the 
serous surfaces of the endocardium — urea in the blood during Bright's 
disease and the blood of rheumatic or syphilitic subjects. It may occur 
after diphtheria and fevers of all kinds. 

Rejection is the rule in all degrees of endocarditis. 

Valvular Lesions. 

(1.) Obstructive lesions, caused by thickening of the valves, with slight 
retraction and adhesions, atheromatous and calcareous degeneration ; re- 
sulting usually from chronic endocarditis, causing obstruction to the blood 
current and valvular murmurs. 

(2.) Regurgitant lesions or insufficiency of the valves, caused by ex- 
tensive valvular retraction, perforation, partial detachment of valves, rup- 
ture of the chordse tendineae, the formation of calcareous plates, which pre- 
vent closure of the valves and allow the blood to regurgitate. 

(3.) Both of these pathological conditions may coexist, the one being 
more extensive than the other. 

(4.) Valvular lesions of the right heart are rare, because endocarditis 
on that side seldom occurs. When found they are generally secondary to 
lesions of the left side of the heart. 

Rejection. — No responsible company will insure these risks. 

Valvular Lesions of the Left Heart, 
aortic obstruction. 
Definition. — An abnormal condition of the aortic valves, as before de- 



138 The Life Insurance Examiner. 

scribed, obstructing the flow of blood from the left ventricle into the aorta, 
which is always accompanied by hypertrophy of the muscular wall of the 
left ventricle. 

Causes. — Acute or chronic endocarditis ; prolonged and severe muscular 
exercise under adverse conditions ; atheromatous degeneration of the aorta. 
It generally occurs in middle or advanced life. Symptoms. — Pulse small, 
compressible, jerking or intermittent; oedema of the feet from defective 
return circulation through the veins, etc. Cardiac impulse increased ; apex- 
beat increased and moved to the left ; increased area of dullness to the left 
and downward ; a direct murmur, systolic, replacing or following the first 
sound of the heart, heard with greatest intensity at the base of the heart and 
propagated along the carotids. Differential Diagnosis. — From mitral re- 
gurgitant murmur, which is also systolic, but is heard with maximum in- 
tensity at the apex, and has its sound carried to the left and behind, also 
audible at the base. From tricuspid regurgitant, whose greatest intensity 
is at the apex, but is seldom audible above the third rib and has the sound 
propagated towards the epigastrium. From an anaemic murmur, with 
which the pulse is soft, full and compressible, the apex beat feeble, the 
sound being a venous hum heard over the carotids. 

Aortic Regurgitation. 

Definition. — One of the gravest heart lesions. The semi-lunar valves 
may be shortened or shrunken by endocarditis preventing closure; or 
lacerated, dilated or adherent, causing a free opening, allowing regurgitation 
of blood, dilatation of the left ventricle, and followed by compensatory 
hypertrophy. Endocarditis is produced, and also distension and degenera- 
tion of the arteries, leading often to rupture of the arteries in the brain. 
Tissue degeneration of the walls of the heart ensues from obstruction to the 
coronary vessels. Dilatation of the ventricle increases and the mitral valves 
become insufficient from pressure and extension of disease. Finally there 
is a disturbance of the venous circulation, resulting in cyanosis and dropsy. 

Causes. — Acute or chronic endocarditis, excessive muscular exercise, 
atheroma of the aorta. Symptoms. — Pulse quick, hard, jerking, irregular 
and intermittent, delayed after the apex-beat of the heart ; palpitation of 
the heart and hypertrophy; dispncea from pulmonary congestion, etc.; in- 
creased area of the apex-beat, carotid pulsation, heaving impulse to the left of 
the nipple about the eighth rib ; area of precordial dullness to the left and 
below the normal area, which extends towards the axillary space as dilata- 
tion increases ; an indirect murmur, diastolic, with or following the second 
sound of the heart, heard at the base of the heart and down along the 
sternum to the ensiform cartilage ; when combined with aortic obstruction, 
there is a double murmur heard over a large area. Differential diagnosis 
rests on the presence of a diastolic murmur and the coexistence of dilata- 
tion and hypertrophy of the left ventricle. 



The Life Insurance Examiner. 139 

Mitral Obstruction. 

> ' Definition. — It is a condition of stenosis of the auriculo-ventricular orifice 
of the left heart, caused by constriction at the base of the mitral valves, 
adhesion of valve-tips and chordae tendineae, following rheumatic endocar- 
ditis, principally in young children. The mitral opening, which should 
admit the tips of three fingers, often becomes a mere " button-hole slit." 
Dilatation and hypertrophy of the left auricle follow from over-distension, 
also pulmonary congestion from obstruction in the pulmonary veins. 
<( Brown pigmentation or induration " of the lungs and bronchorrhcea are 
common sequelae, or pulmonary apoplexy may occur during exercise, and 
finally pulmonary oedema. 

Causes. — Acute or chronic endocarditis in young people, morbid changes 
in the blood, urea in Bright's disease, rheumatism, any of the fevers. Symp- 
toms. — Pulse regular but feeble if stenosis is extensive; dispncea from pul- 
monary congestion ; dry, hacking nervous cough ; or there may be profuse 
watery expectoration ; blood-stained sputa after exercise ; feeble cardiac 
impulse, a distinct purring thrill preceding the apex-beat ; area of dullness 
increased upward and to the left ; a presystolic, loud, blubbering murmur 
heard just before the first sound, with maximum of intensity a little above 
the apex-beat, usually not transmitted and louder than any other murmur. 
Differential diagnosis depends on the purring thrill and loud, blubber- 
ing murmur. It may be confused with mitral and aortic regurgitation. 

Mitral Regurgitation. 

Definition. —It is caused by thickening, induration and shortening of 
the mitral valves, due to endocarditis. The valves may be imbedded with 
calcareous matter, or torn, the chordae tendineae may be ruptured, causing 
them to flap, or they may become adherent to the ventricular walls. 

Secondary changes likely to follow : (1.) Dilatation of the left auricle 
from over-distension. (2.) Compensatory hypertrophy of left auricle to 
force the blood through the smaller orifice. (3.) Disturbed pulmonary 
circulation, causing congestion or brown induration. (4.) Hypertrophy of 
the right ventricle to overcome pulmonary obstruction. (5.) Dilatation of 
the right ventricle from too much pressure. (6.) Tricuspid regurgitation, 
due to excessive dilatation of the ventricle, or to an endocarditis set up in 
the valves. (7.) Dilatation of the right auricle from the pressure of regur- 
gitated blood. (8.) Compensatory hypertrophy of the right auricle to over- 
come previous dilatation. (9.) Interference with the return circulation of the 
venous blood from the superior vena cava, producing headache, vertigo, 
pulsation in the jugular veins, cyanosis, oedema, apoplexy, etc,; from the 
inferior vena cava, producing nutmeg liver, obstruction to the portal cir- 
culation, hemorrhoids, menstrual disturbance, gastric catarrh, epigastric 
pulsation, intestinal catarrh, ascites, jaundice, enlarged spleen, passive 
hyperaemia and catarrhal desquamative nephritis and general anasarca. 



--'- 



(io.) In order to overcome these changes, and sustain the powt: 

Itti::. i..t:t:l : r. = r. t hyt trtrrcl.y :: :lt± It:': vtr.:rl;le -..tally :::t:. 
—Primary: Acute endocarditis. It may be secondary to aortic val 
: r^ ; r : : tr l?.rrt: r.tr : : : : Itt It:: :-. - : 1: . :-vtt:rl: tlar :rir.:e fr:rr. txctiflvt 
tll = :t:i:r. ::' :ltt It:: vtr.:r;:lt. 7/ ' /: .. — M:s: ::":he rt:::r.tl 5y~.; : : n.~ 
in itvt.zzti la:t It z.i ;.;:-: :r:rr. :t -tr^l:i:l : r. t: :ltt :rl:t5tlt irltcr 
of the right heart. Pulse is feeble, compressible and easily accelerated. 
Physical signs, increased area of cardiac impulse, apex beat to the 
trstirtitl i -i.lr.tr ? Ir.crttft t li:trtlly tr. t i : -v r. -.v i r t i rr.t ::;._: :i-:tf :ltt 
z'.LZt : : : : :' : 11: "•"= :ltt r.:«: 5 : .: t : : :' :l.t Itrt::. tr. t if -yr.:r.r:r.:us :1. :ltt 
systole of the left ventricle; its greatest intensity is at the apex: area of 
diffusion to the left and backward. Differential Diagnosis. — In aortic 
regurgitation, the pulse is hard and jerky ; in aortic obstruction, the 
::_:-.: .s ::r.vtytt s..:rg :ltt :tr::iif it :rl:_ftlt rt-tr_;i:t:: : r. ::.t 
murmur is heard over the right ventricle, and to the right of the heart, 
while in mitral regurgitation the murmur is heard at the apex, an 1 
vtytt :: :ltt It:": ~-.i ': i:l: vi-y 

Valvular Diseases of the Right Heart. 
These are rare, because endocarditis seldom occurs on tha: md, 

when present, are secondary to valvular lesions of the left heart. Endo- 
carditis of this side is usually confined to the tricuspid valves, and is c 
obstruction in the pulmonary circulation from mitral disease, which super- 
induces hypertrophy of the right ventricle and disease of the val 

Pulmonic Obstruction or 5:: 
It is generally due to the pressure of mediastinal tumors upon the pul- 
monary artery. Symptoms. — The murmur is systolic, superficial ant 
tinct, heard- with the first sound, its maximum of intensity being at the 
second left costal cartilage, and the sound is diffused towards the left 
5- : -litr. 

Pulmonic Regurgttati : 

71. 5 tt:lt:l :gt:il ltsl:t is tx:rt~7.y :^:t t.tty = t:"t:r:::t5 i:7t:i.t- 
its existence under any circumstances. Theoretically, the murmur is iias- 
tolic, occurring with the second sound, is heard at the base cf the heart, 
the sound being loudest over the valve at the second left costal cartilage. 
If extensive, this lesion would cause dilatation of the right ventricle, tricus- 
z'.i rer_:r ::.:! :t ttt ti5:tr'ttr.:t ::' :.:t =ys:tttl: :lr;tli:;:t. 

7:::.?:: 1.::::.:::a::::" 
It is commonly secondary to mitral obstruction or regurgitation, and 
preceded by hypertrophy of the right vertricle from the strain of overcom- 

. t r r -Irr. : t. : ::;::.: ::1 : t. 7 Itt valves : It . : -: t r. ttt sltrlt.-:. is t: :tt :.a : rt at 
tendineae. There is first dilatation, and, secondly, a compensatory hyper- 



The Life Insurance Examiner. 141 

trophy of the right auricle ; disturbance of the circulation in the venae 
cayae, as described under mitral regurgitation ; and, lastly, the left ventricle 
is hypertrophied in the effort to overcome the systemic obstruction. 

Causes. — Its spontaneous origin is doubtful. Pulmonary emphysema 
causes it by interfering with the pulmonary circulation, throwing abnormal 
stress on these valves and inciting endocardial inflammation ; also, any in- 
terference with the pulmonary circulation, such as mitral lesions, mediastinal 
tumors pressing on the pulmonary artery, etc. 

Symptoms. — When the venous return circulation is interfered with, 
there are many rational symptoms, such as headache, vertigo, cardiac pal- 
pitation, dispncea, cyanosis, etc. Physical signs — increase of visible cardiac 
impulse, pulsation and distension of the jugular veins ; indistinct apex-beat, 
unless hypertrophy of the left ventricle exists ; epigastric pulsation ; area of 
dullness increased to the right of the sternum ; a blowing murmur taking 
the place of the first sound of the heart, systolic, superficial and scarcely 
heard above the third rib ; the maximum of intensity is at the left border of 
the sternum, between the fourth and sixth ribs, the second sound of the 
heart being more intense over the pulmonic valves. 

Differential Diagnosis. — From mitral regurgitation, aortic obstruction 
and tricuspid obstruction. 

Tricuspid Obstruction. 
Symptoms. — This murmur, like the mitral obstructive, is presystolic, its 
greatest intensity being heard along the margin of the fifth and sixth ribs 
on the left border of the sternum, and its sound is not transmitted far. 



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The Life Insurance Examiner. 143 

Inorganic Functional Murmurs. 

>ANiEMlC, ELEMIC OR Blood MURMURS. — With reference to these 
arterial functional murmurs, Loomis remarks : " They are soft and blowing 
in character, almost always systolic and aortic. As regards their area, they 
are generally diffused, not only over the base of the heart, but along the 
course of the aorta and vessels of the neck. 

" Differential Diagnosis. — An anaemic murmur is distinguished from an 
organic murmur by its blowing character, by always accompanying the first 
sound of the heart, by being audible in several arteries at the same time, 
by not being constantly present, and often disappearing when the circula- 
tion is tranquil ; by the presence of the general symptoms of anaemia and 
absence of the physical signs of organic heart disease, and by complete 
disappearance after the cure of anaemia." 

VENOUS Murmurs. — (Loomis.) " The so-called ' venous hum ' is a 
continuous humming sound, best heard over the jugular veins, just above 
the clavicles, when the patient is sitting or standing. It is characteristic of 
anaemia, and is generally associated with an arterial anaemic murmur." 

POSTPONEMENT. — Postpone until both the cause and the murmurs 
are removed. A re-examination will decide the question of acceptance. 

Ventricular Murmurs. 

Ventricular Murmurs. — (Loomis.) " Sometimes a murmur is heard dur- 
ing the progress of or after endocarditis, taking the place of or following the 
first sound of the heart, which is undoubtedly produced within the cavity 
of the left ventricle, by the roughening of the chordae tendineae, or the surface 
of the valves, or perhaps by an abnormal direction of the current of blood 
in its passage through. These may be distinguished from other murmurs 
by the time of their occurrence and their limited area of diffusion, not being 
heard to the left of the apex or along the aorta." 

Rejection. — These rare bruits also reject. 

Induced Cardiac Sounds. 

Sounds which are neither endocardial, pericardial or functional, the 
same authority states, may be heard in the precordial region, produced by 
the movements of the heart upon the lungs. These sounds are mostly sys- 
tolic and respiratory, ceasing when the breath is held. 

POSTPONEMENT. — Postpone and re-examine so as to be sure of the 
absence of organic murmurs, or of any other uninsurable condition. 

Pericardial Murmurs. 

Pericardial murmurs or friction sounds, like those of pleurisy, are caused 

by the rubbing together of the roughened surfaces of the serous membrane 

lining the pericardium after inflammation of that membrane, and during the 

movements of the heart. They are rubbing, creaking or rasping sounds 



144 The Life Insurance Examiner. 



and distinguished from pleuritic friction sounds by being limited to the pre- 
cordial space and being synchronous with the cardiac, instead of the 
respiratory movements. These sounds vary in intensity from a slight 
rustling to a loud rasping, becoming, as a rule, more distinct during expira- 
tion than inspiration ; when the person sits than when he lies. Differential 
Diagnosis. — From endocardial valvular murmurs they are distinguished by 
their rubbing quality, superficial character, and by not being transmitted 
beyond the pericardial area, by their independence of the heart sounds and 
by their increased intensity when the person is in a sitting position. 

Pericarditis. 

Definition. — Pericarditis signifies inflammation of the serous sack en- 
closing the heart, and, like pleurisy, passes through the stages of plastic 
and serous effusion and absorption, generally terminating in recovery un- 
less complicated with Bright's disease or some infectious blood disorder. It 
is a secondary disease and occurs chiefly in young people. Causes. — Ex- 
tension of inflammation from other diseases, such as pneumonia, pleurisy 
necrosis of the sternum and ribs, or from certain blood diseases, as acute 
rheumatism, Bright's disease of kidneys, scarlet fever, small pox, typhus, 
tuberculosis, syphilis, alcoholism, scurvy, purpura, etc. Symptoms. — The 
acute stage is never seen in the examining room, but in some cases of chronic 
pericarditis, the sack may contain some fluid, chalky debris, calcareous 
plates ; or adhesions and roughening of the membrane may remain. Physical 
Signs. — Besides the friction sounds above described, which may be heard, 
a marked case presents depression of the precordial region from adhesions 
between the pericardium and the chest walls ; indistinct apex beat, often 
two inches higher than normal, displaced cardiac impulse and irregular 
movements of the heart, and increased dullness in the pericardial region. 

REJECTION is necessary in all cases showing effusion, or adhesions 
which restrain free cardiac movements, or when there is a history of repeated 
attacks. 

ACCEPTANCE is admissible only in those cases where there is entire 
absence of rational and physical signs of the disease, which is an indication 
of complete recovery. 

Cardiac Hypertrophy. 
Definition. — Hypertrophy of the heart consists of a thickening of the 
walls of the heart from an increase chiefly in the number (hyperplasia) of 
the muscular fibres, involving both the auricles and ventricles. Varieties. 
— The simple fiorm, where there is thickening of the walls, without enlarge- 
ment of the cavities ; it is confined to the left ventricle and occurs chiefly 
in Bright's disease and alcoholism. The Excentric. — Where there is thick- 
ening of the walls, with enlargement of the cavities. Co7icentric. — Where 
there is thickening and diminution of the capacity of the cavities, a very 






The Life Insurance Examiner. 145 



rare variety. Causes. — It seldom exists without valvular lesions, arterial 
changes or capillary obstruction. Aneurism, pericarditis with adhesions ; 
Bright's disease, emphysema, long-continued functional disturbances of the 
heart, habitual excessive exercise, straining, etc., are some of the assignable 
causes. In some cases it is congenital. Symptoms. — In moderate cases; 
pulse full and strong, carotid distension and pulsation, face easily flushed, 
etc. In severe cases; feeling of fullness in the chest, dispncea, palpitation, 
headache, vertigo, atheroma and endarteritis of the arteries from extension 
of the endocarditis, etc. Physical signs — Increased area of pulse, heaving 
of the chest, bulging of the precordial space and displaced apex-beat, 
especially in children ; increased area of apex-beat, strong epigastric pulsa- 
tion with hypertrophy of the right ventricle. In hypertrophy of the left 
ventricle the apex-beat will be three inches below and two or three inches 
to the left of the nipple. In excentric hypertrophy of the right ventricle, 
the apex-beat is displaced to the right and downward. Percussion dullness 
is increased to the right or left, according as the right or left heart is 
affected. Auscultation gives, in the absence of any murmur, a prolonged 
dull, muffled first sound, with increased intensity ; also increased intensity 
of the second sound. Left hypertrophy gives the loudest sound over the 
aortic orifice ; right, over the pulmonic orifice. Absence of respiratory 
murmur over the precordial space. 

In hypertrophy with emphysema of the lungs, the apex-beat may not 
be much increased in force; the heart sounds will be diminished and there 
may be pulsation in the veins of the neck, due to hypertrophy and dilata- 
tion of the right ventricle, with tricuspid regurgitation. 

Differential Diagnosis. — In excentric hypertrophy of the left ventricle, 
there will be a full and strong pulse, carotid pulsation, flushed countenance, 
apex-beat forcible and diffused to the left and downward, cardiac dullness 
extending in the same direction, and marked intensity of the second sound 
of the heart. In the same condition of the right ventricle there will be 
increased heart's action and dullness to the right and downward, epigastric 
impulse, and marked intensity of the first sound. In total excentric hyper- 
trophy the same signs will be present as in that of the left heart, with dull- 
ness increased in all directions, and intensity of both sounds. 

Rejection is imperative. 

Cardiac Dilatation. 
Definition. — There is increase in the capacity of the heart cavities and 
a diminution of contractile power. Varieties. — (1.) Simple form, where 
there is increase of capacity with no change in the walls of the heart, occur- 
ring after fevers and wasting diseases. (2.) Hypertrophic — increased capacity, 
and thickness of the heart-walls, with diminished contractile power. (3.) 
Atrophic — marked increase in capacity of the cavities and thinning of the 
heart-walls. Frequency. — It occurs most frequently in the auricles, next in 



:_■;' . hi Ljfi I: :b Ex.v:: 

the right ventricle, and last in the left ventricle. Causes. — Cardiac c 
tion ensues : From internal pressure during diastole, from wea- 
after prolonged sickness, fatty degeneration, and absence of compenf- 
hypertrophy. (2.) From loss of tone when the heart muscle is the seat of 
prim?. ■ degeneration, and after myocarditis. 5. Prom ..tion 

of muscle, which is the seat of excentric hypertrophy, oc; 
ular disease. 

Sj — In simple dilatation, when the cavities are increased and 

the heart's action is labored, there is no increase of force, but the : 
pulse is feeble. In atrophic dilatation, the cavities are dilated and 
the walls thinned, with a feeble and intermitte: labored 

heart's action of feeble p rngorged, arterie 

ncea, palpitation, sense of cardiac pulsation, 1 
cyanosis, oedema, etc. Physical signs— 1 -:inct and increased area : 
pulse in fat subjects: undulatir . _ ment over the precordial sp 

thin people, prominent jugular veins if the right hear: 
cardiac impulse, apex-be purring thrill with the 

-itation coexist?. Increased dullness latera" . area 

of dullness is not increased, as in kypertrof 

dilated the area of dullness is increased u| in dilatation of the 

auricle the .re dilated. Auscultatic 

- rounds to be short, feeble and nearly equal, and the sec 
audible except direc: G aortic orifice. 

exercise. The differential diagnosis is c ■': 

-resenting any degree of 
refused. 

Hy: ni Dilatation. 

These conditions often coexist and d ziaracter 

according to the preponderance of one or the other. 

Rejection native. 

Cardiac Thrc 1 : 1 . 

r — Heart clots m r be formed . 

cavities just previous to death. They are of all shapes size 

from a pin's head to a v vhen small being called weg 

when large, thrombi. They are found in the cavities or on the 

_-. — When detached : at along and plug up some portion of 

the arteries according to their size, producing symptoms 
situation. When they remain in the heart the ict the current of 

blood therein, to a greater or less extent, causing irregular cardiac inn 
and dullness to the right of the sternum A . s cultation shows marked ii 

• of the heart's action, and murmurs indicative of tricuspid or pulmonic 

ruction. 



The Life Insurance Examine k. 147 



REJECTION. — When the condition can be demonstrated, the prognosis 

is always grave and the candidate must be refused. 

> ■ 

Cardiac Atrophy. 

This condition of the heart, aside from the atrophic form of dilatation 
or active degeneration, is recognizable by the general cachexia and the 
physical signs of a weak heart. It is associated with wasting diseases and 
universally demands rejection. 

Cardiac Fatty Degeneration. 

Tivo Varieties. — (1.) Quain's fatty degeneration of the primitive mus- 
cular fibres, which lose their nuclei and striated appearance and become 
granular, etc. (2.) There may simply be an increase of fat in the areolar 
tissue between the muscular fibres, causing pressure upon them, in which 
condition the heart is pale, flabby or yellowish, and may be increased in 
bulk. The first form is a true fatty metamorphosis, due to malnutrition; 
the second, an adipose condition, due to an excess of fat in the blood. Predis- 
posing Causes. — (1 .) Malnutrition and obstruction of the coronary arteries. (2=) 
Excessive or perverted nutrition, causing a deposit of fat. Exciting 
Causes.— Bright's disease of the kidneys, alcoholism, gout, phthisis, cancer, 
calcification of the coronary arteries, pericardial thickenings, causing com- 
pression, poisoning by phosphorus, chloroform, etc , and general obesity. 
Symptoms. — Rational symptoms of weak heart. Physical Signs. — Feeble 
respiration, indistinct apex-beat, rolling motion of the heart, increased area 
of dullness, first sound feeble or absent, second sound feeble but distinct. 
Differential diagnosis from cardiac dilatation. It may be recognized by ex- 
clusive diagnosis, and the arcus senilis is often present with it. In all cases 
of rapid obesity, guard against overlooking this disease by a rigid examina- 
tion. 

REJECTION is always demanded. 

Myocarditis. 

Definition. — Myocarditis is an inflammation of the muscular structure 
of the heart, associated with two kinds of degeneration and softening. (1.) 
General or diffused, which is very rare. (2.) Local or circumscribed, met 
with in pericarditis and endocarditis, usually involving only the external or 
internal surface of the heart. The left ventricle is most frequently affected, 
and the process terminates either in connective tissue formation, or in ab- 
scess and possible rupture of the heart. Predisposing causes are rheuma- 
tism, terminating in connective tissue induration ; endocarditis, pericarditis, 
syphilis, high fever. Exciting Causes. — Embolism of the coronary arteries, 
pyaemia, ending in abscess, septicaemia, typhus and typhoid fevers. Symp- 
toms. — Feeble, irregular and intermittent pulse, palpitation, etc. Area of 



148 The Life Insurance Examiner. 



precordial dullness increased upward and to the left, without heaving im- 
pulse, as in cardiac hypertrophy. 
Rejection invariably the rule. 

Cardiac Malformations and Displacements. 
REJECTION follows the detection of any of these anomalies, as indi- 
cated by the physical or rational signs, such as congenital malformations or 
displacements, or those caused by effusions, tumors, aneurism, etc. 

Nervous Cardiac Palpitation. 

Definition — Palpitation is often a neurosis of the heart, independent of 
any organic disease. Causes. — Excessive growth, violent exercises, alcohol- 
ism, debility, anaemia, sexual excess, typhoid fever, dissipation, late hours, 
strong tea, coffee, tobacco, shock, fright, dyspepsia, gout, etc. 

POSTPONEMENT. — Provided no organic disease exists, the Examiner 
should postpone these cases, remand them to the care of the family phy- 
sician, and re-examine at some future time. 

Angina Pectoris. 

Definition. — Angina is a neurosis, dependent chiefly upon organic 
heart changes, causing a weak heart. It is especially associated with ob- 
struction in the coronary arteries and fatty degeneration of the heart. Some 
assert that the cardiac spasm is reflex from some disorder of the pneumo- 
gastric or cardiac plexus of nerves. Predisposing Causes. — Obstruction to 
the coronary circulation from aortic regurgitation, or atheroma or embol- 
ism of the coronary arteries, fatty degeneration. Exciting Causes — Mental 
emotion, over-exercise, excess in diet or stimulation, bad air, etc. 

Symptoms. — Pain, intense, stabbing, shooting through to the back and 
along the left arm, sense of suffocation, face pale and anxious, livid, cov- 
ered with cold sweat, pulse faltering and thready, dispncea, etc., respiration 
short and hurried, often a heart murmur, if due to valvular lesion, or the 
signs of fatty degeneration. Differential Diagnosis. — From spasmodic 
asthma by the absence of heart lesions. In hysteria, the pain and rational 
symptoms are less intense. In intercostal neuralgia, the absence of cardiac 
disturbance. In neuralgia, the condition of the circulation, location and 
direction of pain, and the physical signs exclude angina pectoris. 

Rejection. — Rejection is imperative. 

Basedow's Disease. 

Synonyms. — Grave's disease, exophthalmic goitre. This is a disease 
characterized by palpitation of the heart, accelerated cardiac action, pulsa- 
tion of the veins of the neck and head, swelling of the thyroid gland, and 
protrusion of the eye-balls. 

Causes, — It is more common among women than men, and may follow 



The Life Insurance Examiner. 149 

menstriKil disorders or anaemia. Protrusion of the eye is caused by a vaso- 
motor paralysis of the blood vessels, which may affect the heart also, or by 
the presence of intra-orbital fat, abscess, tumors, or exostosis of the bone. 
Symptoms. — Rapid pulse — 120 to 140 per minute — palpitation, blood mur- 
murs, rustling- sound in the thyroid gland, which is swollen ; cerebral symp- 
toms, etc. 

REJECTION. — Rejection is imperative. 

Diseases of the Arteries. 

thoracic aneurism. 

Definition. — Arveurism is a local dilatation of an artery, forming a 
tumor which contains blood. Aneurisms of the thoracic aorta are first de- 
scribed. Diagnosis is best made by the methods of physical examination. 
Symptoms — Inspection. — When the aneurism presses on the superior vena 
cava, the face, neck and upper extremities are swollen, often livid, with 
turgid and varicose veins. When the pressure is on the innominate veins, 
these effects are on the corresponding side. There may be bulging of the 
chest along the course of the aorta, except when the aneurism is deeply 
seated. Pulsation of the tumor may be observed, synchronous with the 
heart's systole. When the tumor is full of fibrin, the pulsation may not 
be perceptible. Aneurisms of the ascending arch produce bulging to the 
right of the sternum, near the second costal cartilage ; of the transverse 
arch, protrusion of the upper part of the sternum ; of the descending arch, 
at the left of the sternum. Palpation often yields a pulsation and a 
thrill. The impulse is usually systolic. Percussion gives dullness over the 
prominence and auscultation often an audible murmur. Differential Diag- 
nosis. — Intra-thoracic solid tumors seldom pulsate, and do not yield a 
murmur. Aneurism of the arteria-innominata appears on the right of the 
sternum, protrudes the inner part of the clavicle and the neck. Pressure 
on the carotid or subclavian artery, suspends the pulsation, which is not 
thus affected in aneurism of the aorta. 

Rejection. — Aneurism absolutely rejects. 

Diseases of Arteries. 

Arteries are subject to morbid changes in their coats. Varieties. — 
Acute and chronic arteritis ; the latter, some authorities say, merges into 
atheroma ; periarteritis of the smaller arteries, giving rise to cerebral hem- 
orrhage. 

Atheroma, or the endarteritis deformans of Virchow, is most common 
and most serious. It is most frequent in the aorta ; then in the cerebral, 
coronary and splenic arteries and those of the lower extremities. The chief 
cause is overstraining of the artery. Fatty degeneration and calcification 
may accompany atheromatous disease, and syphilitic gummatous disease 



150 The Life Insurance Examiner. 

and albuminoid disease are sometimes found. These diseases tend to the. 
production of apoplexy, aneurism and senile gangrene. 

Rejection is necessary whenever the condition is detected by means 
of rational or physical signs or in the radial pulse. 

Sunstroke or Insolation. 
(See Diseases of the Nervous System, Part III ) 

Diseases of the Veins. 

varicose veins. 
ACCEPTANCE of applicants with extensive varicose veins is questionable, 
because they often indicate progressive weakness of the circulation, which 
may become alarming at any time. They should present unexceptionable 
claims to insurance in all other respects, and the varicose veins should be 
very slight. If otherwise decline peremptorily. 

HEMORRHOIDS. 
POSTPONEMENT. — When present at the examination, piles, whether 
hemorrhagic, or of a mild or severe grade, should postpone the case until the 
applicant is free from the condition and the cause is demonstrated to be 
merely local and temporary. If the applicant has been operated upon, the 
attending surgeon's certificate as to the success of the operation should be 
demanded. If a condition exists at the time of the examination which 
requires operation, postpone the applicant until the completion of the cure. 

The Pulse in Disease. 
POSTPONEMENT — A pulse rate over ninety or under sixty beats to the 
minute is ground for postponement and re-examination. (See Exami- 
nation of the Pulse, Part II., and also page 16, Part I.) 



DISEASES OF THE ALIMENTARY AND ABDOMINAL 

ORGANS. 

Diseases of the Mouth, Fauces and Pharynx. 

Inspect the condition of the mouth, teeth, gums, tongue, parotid, 
submaxillary and sublingual glands, fauces, tonsils and pharynx. Any 
morbid affection of these parts may point to something more serious 
in the general system. Search for the various forms of stomatitis, ulcer- 
ations of all kinds, diseases of the tongue, evidences of acquired or inherited 
syphilis, salivation, sore throat, tonsillitis, abscesses, pharyngitis, diphtheria, 
etc. (See Diseases of the Respiratory Organs, Part III.) 



The Life Insurance Examiner. 151 



The Tongue. 

> A critical examination of the tongue often gives important clinical 
information, both as regards local disease and morbid processes going on in 
remote organs. The distinguished Dr. F. T. Roberts of England, sets forth 
the results of a systematic examination of the tongue, as follows: (1.) Its 
subjective sensations are the ordinary sense of touch and taste. Dr. Quain 
reports that a gouty diathesis is sometimes associated with a peculiar sense 
of heat and burning in the tongue. 

(2.) The movements of the tongue are observed during articulation and 
deglutition. In many cases of cerebral disease one-half of the tongue is 
paralyzed in its muscles and often becomes furred and very foul. It is 
specially affected in certain nervous diseases, indicated by difficulty of speak- 
ing and swallowing, or complete paralysis. (3.) The objective examination 
of the tongue reveals all abnormal conditions indicative of functional or 
organic diseases. Allowance should be made for the effects of certain 
habits upon its appearance, such as the use of tobacco, stimulants, prepara- 
tions of iron and other medicines, neglect of brushing the teeth, etc. 

(4.) Effect of various diseases on the tongue : In febrile states the 
tongue is covered with yellowish white fur. In typhoid fever it is small, 
irritable, furred, or red and glazed ; in scarlet fever its papillae are enlarged 
and red, giving the strawberry appearance ; in diphtheria it often has the 
characteristic deposit, etc. Constitutional syphilis causes patches or con- 
dylomata. A pale, flabby tongue indicates anaemia. An enlarged plethoric, 
livid, furred tongue is seen in congestions and inflammations of the diges- 
tive organs and liver ; in obstructed venous circulation or deficient aeration 
of the blood, from heart and lung affections, or from the pressure of tumors, 
effusions, abscesses or aneurisms. In local affections of the mouth and 
throat the tongue is furred ; in gastritis it is red, dry, with enlarged papillae ; 
in chronic dyspepsia of the atonic form it is large, pale and flabby ; in 
chronic diarrhoea or dysentery it is tender, glazed and frequently studded 
with ulcers ; in diabetes mellitus it is clean, red, dry and cracked, also in 
peritonitis and phthisis. The Examiner should also observe the tongue 
carefully for indications of any intrinsic disease. 

Diseases of the CEsophagus. 
Diseases of this portion of the alimentary canal are not as common as 
those of that part below the diaphragm, but they deserve mention, and 
should be recognized. They comprise inflammation, ulceration, stricture, 
cancer, paralysis, dilatation and neuroses. 

Organic Stricture. 
Organic stricture of the oesophagus takes place more frequently in the 
lower third, but may occur in any portion. Above the stricture the canal 
is dilated, and its walls are thickened, while below, the walls are thinned 



iq2 The Life Insurance Examiner. 



and the canal collapsed. Morbid Anatomy. — Stricture of this organic 
nature is due to cicatricial contractions following considerable loss of sub- 
stance, as in corrosions or ulcerations ; to hypertrophy of the muscular 
and inter-muscular connective tissue ; or to chronic catarrh or hypertropy of 
the submucous tissue. 

Causes. — It may be caused by swallowing strong acids, alkalies, or 
corrosive poisons ; by the lodgment of foreign bodies, which set up inflam- 
mation ; by compression due to swelling of the thyroid gland ; by swelling 
of the lymphatic glands, dislocation of the hyoid bone, exostosis of the 
vertebrae, abscess, tumors, cancer, aneurism, cancer of the lungs, dilatation 
of the right subclavian artery, etc. Symptoms. — Increasing difficulty in 
swallowing, especially solid food ; pain about the manubrium and back ; 
regurgitation of food, constipation and progressive emaciation. Passage of 
the oesophageal bougie will settle the diagnosis. 

Rejection of all such cases is the universal rule. 

Nervous Affections. 

Globus hystericus is one form of spasmodic stricture of the oesophagus. 
It is a condition of hypersesthesia, or increased excitability of the sensory 
nerves ; there is a feeling as though the tube were ligated, with inability to 
swallow. It occurs principally in nervous people and hysterical women, or 
as a reflex in pregnancy and uterine diseases. 

Hyperkinesis, or dysphagia spastica, is an increased excitability of the 
motor nerves of the oesophagus. The spasm is reflex and forms a symptom 
of some diseases of the brain or upper part of the spinal cord. Or it may re- 
sult from narcotic poisoning, or from alcoholism. It usually comes on dur- 
ing the act of eating. 

Akinesis is a diminished excitability of the motor nerves, often accom- 
panying brain or spinal cord disease. When complete paralysis exists, there is 
no power to swallow food ; in incomplete paralysis large pieces of solid food 
may be swallowed. Differential Diagnosis. — From organic stricture these 
affections may be distinguished by their sudden appearance and disappear- 
ance, and the absence of permanent symptoms of pain, dysphagia and ob- 
struction. The use of the bougie will confirm or disprove the diagnosis. 

POSTPONEMENT is required in all doubtful cases. 

Dilatation. 

Total Dilatation of the oesophagus sometimes happens, when the canal 
may become the size of a person's arm, with thickened or thinned walls. It 
is due to chronic catarrh, which induces muscular paralysis. 

In Partial Dilatation the portion above the stricture is usually largest. 
Diverticuli (local enlargements, developing into large sacs, formed by for- 



The Life Insurance Examiner. 



'53 



eign bodies that have lodged in the walls of the canal) are generally found 
near the-bifurcation of the trachea. 

> Symptoms of partial dilatation are: first, retention of food, then regur- 
gitation of food mixed with mucus. The diverticuli may be felt as soft 
tumors in the neck, which may cause dispnoea by compressing the pneumo- 
gastric, laryngeal or phrenic nerves. 
Rejection.— Invariably. 

The Abdomen. 
(For a general view of the alterations in form caused by abdominal 
diseases, see " Examination of the Abdomen," Part II.) 

Diseases of the Stomach, 
gastrodynia. 

Definition. — Gastrodynia, or nervous cardialgia, is a painful affection of 
the stomach not dependent upon any organic change, but upon hyperesthe- 
sia of the pneumogastric nerve, or of the solar plexus of the sympathetic. 
Causes. — Impoverishment of the blood from anaemia or chlorosis, espe- 
cially in females, uterine and ovarian disorders, cerebral and spinal diseases, 
disease of, or pressure upon the pneumogastric or sympathetic nerves ; 
dyscrasia, excessive acidity, worms, medicines and beverages of a certain 
kind. Symptoms. — Paroxysms of severe pain, a sense of pressure and griping 
in the pit of the stomach, faintness, epigastric pulsation, eructation of gases 
and acrid fluid, etc. Differential Diagnosis must be made from ulcer of the 
stomach, etc. 

Postponement. — Postpone candidates who present these symptoms. 
Subsequent re-examination may afford evidence of recovery, or may enable 
the Examiner to exclude more serious lesions of the stomach. 

Functional Dyspepsia. 

Definition. — Functional or atonic dyspepsia, or indigestion, signifies 
some derangement of the physiological process of digestion, without any 
corresponding structural changes in the stomach. It is very frequently 
brought to the notice of the Examiner, who is expected to recognize it 
and differentiate it from those forms of dyspepsia which are either the fore- 
runners or the symptoms of organic diseases. He should remember that 
it may be a harmless symptom of a functional nature, or, on the other hand, 
a condition which may determine the development of a diathesis or 
cachexia, such as the tuberculous. Dyspepsia interferes with nutrition, 
the abeyance of which is likely to leave the system a prey to any inherited 
taint. 

Too much care cannot be used in contrasting many seemingly trivial 
symptoms with other elements of the examination, so that the applicant's 
expectation of health may be approximately calculated. 



154 The Life Insurance Examiner. 

_ r r state of depressed vitality predisposes to 

atonic dyspepsia; heredity, advancing age, anaemia, lack of exercise or fresh 

: Dri'.e conditions of the system, neurasthenia, a secretion of gastric juice 
which is insufficient for digestion or which allows fermentation to take place. 
Exc *ing Causes, — All causes which produce gastric catarrh, such as excesses 
in eating and drinking, imperfect mastication and admixture of saliva with 
the food, a bad die: loI, irregularity in eating, mental worn- and 

:e: an atonic condition of the muscular layers of the stomach 
which prevent the movements necessary to the process of digestion, etc. 
Symptoms. — Loss of appetite, morbid cravings, flatulence, nausea, eructa- 
tions, pyrosis or ••water-brash." -heartburn" or a burning sensation in the 
stomach, headache, constipation, palpitation, and many sympathetic symp- 
toms. 

POSTPONEMENT. — Postponement is warranted in all cases in which 
dyspepsia is present and seems to be undermining the constitution by pro- 
moting malnutrition, or rendering the general system liable to the develop- 
ment of organic and transmitted diseases. 

ACCEPTANCE. — There are many cases, in which the digestive derange- 
ments are obviously temporary, which need not delay the application. 

Chronic Gastritis. 

Definition. — Chronic gastric catarrh is of ordinary occurrence. In this 
condition the blood vessels of the mucous membrane are dilated, and the 
membrane becomes congested and discolored, and finally thickened. Ridges 
and furrows form on the inner coating of the stomach, which is covered with 
a tough layer of gray mucous. Eventually the pyloric orifice of the stomach 

mes constricted. Causes. — Repeated acute attacks, habitual alcoholic 
excesses, obstructed circulation in the liver, portal vein, or lungs, heart dis- 
ease, the tobacco habit, long continued mental depression or excitement, etc. 
Symptoms, — Sense of pressure and fullness in the stomach, especially after 
eating, swelling of the epigastrium from gas, constant eructations from 
constriction at the pylorus, indigestion, capricious appetite, water-brash, 
scanty urine, emaciation, foul tongue, etc. Vomiting occasionally, though 
rarely, occurs. 

REJECTION. — The unmistakable existence of this complaint calls for 
rejection. 

Chronic Ulceration. 
Varieties of Ulcers found in the stomach are the acute or perforating, 
chronic catarrhal, phlegmonous, scrofulous, syphilitic, diphtheritic, cancer- 
ous, variolous, and those due to corrosive poisons. The ulcer generally 
appears on the posterior wall near the pyloric orifice, and has a circular, 
punched-out appearance. It is from one-fourth to one-half an inch in diame- 
ter. Causes. — Diseases of the wails of the blood vessels anaemia and chloro- 



The Life; Insurance Examiner. 155 

sis, catarrh, or long continued pressure in one position, as occurs in certain 
occupations, such as sewing. Symptoms. — Constant epigastric pain, which 
is aggravated by eating and by pressure over the ulcer. If the pains are 
increased directly after taking food, the ulcer is located at the upper end of 
the stomach ; if an hour or two after meals, it is near the pylorus. Vomiting, 
like the pain, indicates the position of the ulcer according as it occurs 
immediately or some time after taking food. Vomiting of blood is a com- 
mon symptom from erosion of vessels. The tongue is red and furrowed, and 
there are increased thirst, chronic constipation, a cachectic look and extreme 
debility. There is a danger of death from hemorrhage, or from peritonitis 
following perforation of the ulcer. 
Rejection is imperative. 

Dilatation of the Stomach. 

Dilatation of the stomach, or gastrectasia, is a condition wherein that 
viscus is permanently enlarged, its muscular layers being stretched, para- 
lyzed and unable to propel its contents into the intestines in a normal 
manner. Three factors enter into the proper performance of this mechani- 
cal act of emptying the stomach — viz., the muscular force, the quantity 
and quality of the contents, and the size of the pyloric opening. All cases 
of gastrectasia depend upon the derangement of one of these factors. 
Stenosis of the pylorus is sometimes compensated by a corresponding 
hypertrophy of the muscular walls, increasing the muscular force to the 
required degree. Causes. — Cancer is the most frequent cause of pyloric 
stenosis; other causes are, the cicatrization of ulcers, hypertrophy of tissue, 
outside pressure from tumors of neighboring parts, stagnation and fermenta- 
tion of food within the organ; muscular and chemical insufficiency may also 
be mentioned as common causes ; impairment of the muscular force occasions 
organic changes in its muscular coats ; mechanical restraint, malnutrition and 
nervous paresis are some of the remaining causes. As a rule, several of them 
act together to produce the condition. Frequency.— it may develop at any 
age, but is most frequent in middle and advanced life, most of the cases of 
atonic dilatation beginning between thirty and forty. It occurs oftenest 
among sedentary subjects, who eat and drink to excess. Symptoms. — Owing 
to the small amount of nourishment actually assimilated, the appetite for both 
solids and fluids may be greatly increased ; there is usually a sense of fullness 
and dull pain in the region of the stomach ; " heartburn " and eructations of 
gas and acrid fluids are common ; vomiting of enormous quantities of ingesta, 
with or without painful retching ; abnormal distention of the abdominal 
walls; shaking the patient yields a splashing sound. The vomiting of undi- 
gested food taken into the stomach a day or two previously is pathogno- 
monic. Without further enumeration of symptoms, it is well for the Ex- 
aminer to look for this not uncommon affection of the stomach among the 



156 The Life Insurance Examiner. 

middle-aged, well-to-do applicants, who desire insurance for large amounts, 
or limited policies. 

Rejection is the invariable rule. 

Cancer of the Stomach. 

Cancer of the stomach generaly begins in the pyloric region, and spreads 
transversely, causing annular stricture. The most common forms of cancer 
in this locality are the scirrhous, medullary and alveolar or colloid, the latter 
lasting a long time before it produces death. The scirrhous cancer begins 
in the sub-mucous tissue, as irregular nodules of a whitish color and cartil- 
aginous density, which finally soften into a black pulp and slough away. 
The medullary variety appears like brain substance, cancer juice exuding 
from it on section ; it spreads more rapidly than the other kinds and may 
attain the size of the hand. The colloid cancer develops more frequently 
as a diffuse degeneration, commencing in the sub-mucous tissues; it con- 
tains a gelatinous fluid. As a rule it extends to adjacent structures, 
especially to the lymphatics, pancreas, liver, transverse colon or omentum. 
It may cause degeneration of the peritoneum and subsequent ascites. Ex- 
tensive ulceration often causes rupture of the stomach and escape of its 
contents into the abdominal cavity. Causes. — Cancer of the stomach may 
occur from inherited tendency or may be of primary origin, but it is gener- 
ally secondary to carcinoma of some other organ. It is more common 
among men between forty and sixty years of age. Symptoms. — Cancerous 
cachexia, dirty yellow color of the skin, emaciation, a sense of pressure in 
the epigastrium, anorexia, vomiting, the presence of a nodular tumor in the 
epigastrium near the navel, and local tenderness, which is increased by 
pressure and by eating food. Coffee-ground vomiting from capillary 
hemorrhage is a frequent sympton. This appearance is caused by the 
action of the gastric juice upon the effused blood. 

(See sections on " Hereditary Influences " and " Nutrition and Dia- 
thesis, Part III.) 

Rejection in all cases. 

Hematemesis. 

Hemorrhage from the stomach is often confounded with hemoptysis, 
or hemorrhages from other sources. It is of much less grave significance 
than hemorrhage from the lungs, but its causation should always be ascer- 
tained, and the prognosis calculated accordingly. 

Causes. — Rupture of distended veins (arterial rupture is rare) ; venous 
congestion of the gastric mucous membrane from obstruction of the portal 
circulation of the liver by blood-clots, or from pressure due to cirrhosis 
of the liver or enlargement of the gall-duct ; destruction of the capillaries 
from yellow atrophy of the liver ; rupture of diseased vessels, varices or 
aneurism ; exhaustive fevers, like yellow fever, typhus, scurvy, etc. ; im- 



The Life Insurance Examiner. 157 

proper food, such as an inclusive diet of meat or vegetables; erosion or 
injury to Ihe walls of the stomach in chronic ulcer or cancer of the 
stomach; corrosive agents ; traumatisms; alcoholism; swallowing of blood 
in nose-bleed or in hemorrhage from the lungs. 

The following table of differential diagnosis is taken from " Peppers 
System of Medicine :" 

Differential Diagnosis. 

HEMOPTYSIS. ILtMATEMESIS. 

(1.) Usually preceded by symptoms of pulmon- (i.) Usually preceded by symptoms of gastric 

ary or cardiac disease. Bronchial hemorrhage, or liver disease, less frequently by other diseases 

however, without such prodromes is not rare. (see causes). 

(2.) The attack begins with a tickling sensa- (2.) The attack begins with a feeling of full- 

tion in the throat or behind the sternum. The ness in the stomach, followed by nausea. The 

blood is raised by coughing. Vomiting, if it blood is expelled by vomiting, to which cough, 

occur at all, follows coughing. if it occur, is secondary. 

(3.) The blood is bright red, fluid or but (3.1 The blood is dark, often black and grum- 

slightly coagulated, alkaline, frothy, and often ous, sometimes acid, and usually mingled with 

mixed with muco-pus. If the blood has re- the food. If the blood is vomited at once after its 

mained some time in the bronchi or a cavity, it effusion, it is bright red and alkaline, or it may 

becomes dark and coagulated be alkaline if it is effused into an empty stomach. 

4 1 The attack is usually accompanied and (4 ) After an attack, the physical examination 

followed by localized moist rales in the chest, of the lungs is generally negative, but there are 

and there may be other physical signs of pul- usually signs of gastric or hepatic disease, 

monary or cardiac disease. Black, bloody stools follow profuse haema- 

Bloody expectoration continues for some time, temesis. 
often for days, after the profuse hemorrhage has 
ceased. 

REJECTION. — Haematemesis rejects, whenever it is clearly caused by 
cancer, ulceration, cirrhosis of the liver, chronic alcoholism, or any unin- 
surable disease. 

POSTPONEMENT for a certain period is required in all other cases, when 
a re-examination will settle the question of acceptance or rejection. 

Diseases of the Intestines and Peritoneum. 
Acute diseases of these parts seldom come under the observation of 
the Medical Examiner; but their sequelae and certain chronic morbid con- 
ditions are common, and should be mentioned. 

Chronic Peritonitis. 
Pathology. — Interstitial thickenings, from one-half to one inch in extent, 
caused by connective-tissue formations, take place in the peritoneum, and are 
usually associated with cancer or tubercle. In tuberculous inflammation the 
omentum may be full of these deposits, over the whole internal and part of 
the external surface of the peritoneum. The two surfaces may be bound 
together by adhesions, distending or diminishing the calibre of the gut. The 
peritoneal cavity maybe filled with effusion, or there may be a sero-purulent 



The Life Insurance Examiner. 



exudation with a limited quantity of pus. Oftentimes the peritonitis is local 
and affects some adjacent organ. If it be in the vicinity of the liver, for ex- 
ample, the capsule of Glisson will be invaded by the disease and hepatitis will 
ensue : or the inflammation may extend upward from the pelvis, and involve 
even- organ in its course. Causes. — Chronic peritonitis is commonly the 
sequel of an ac*te attack, which leaves behind a low grade of inflammation 
that results in those interstitial changes. I: may also follow cancerous or 
tubercular growths or traumatism. SymptoTtis — Following the acute form 
the symptoms are not so obscure. There is pain which has lasted for a 
long time, and is increased by motion or exercise : weakness, emaciation, 
dyspepsia, enlargement of the mesenteric glands, tumor localized along the 
course of the intestines, and late in the disease fluid in the peritoneal cavity. 
Tuberculous symptoms are pain in the abdomen, dyspepsia, diarrhoea alter- 
nating with constipation, morning fever and s i functional derange- 
ment of any organ which may be involved by extension of the inflamma- 
tion. The tubercular form is generally secondary to tuberculosis of the 
lungs, which should, therefore, be carefully examined in all ca 

REJECTION" is the only safe procedure, whenever this perplexing con- 
dition is suspected. 

Chroxic Diarrhcea. 

Causes. — Chronic intestinal catarrh, or catarrhal enteritis, has many of 
the same causes as the acute form, which is seldom seen in the examining 
room. It is the expression of many different pathological conditions and 
accompanies many general and local diseases. It is common in young 
children, as well as at a more advanced age, and occurs oftener among men 
than women. In advancing age it may be due to failing digestion, portal 
congestion, gouty diathesis, etc. Hereditary influences, bad hygiene — 
occurs among soldiers in camps, in prisons and workhouses, etc.— overwork 
and anxiety are also causes. It is often the accompaniment of chronic con- 
stitutional diseases, such as phthisis, Bright 's disease of the kidneys, gout, 
blood poisoning, scurvy, diabetes, fevers, etc. Diseases of the liver, heart 
or lungs may produce i: : Dndary congestion : an unsuitable diet, 

lodgment of foreign bodies in the intestines, or any chronic intestinal affec- 
ti@n, may give rise to chronic diarrhoea. 

PatJwhgy. — The changes involve the walls of the intestine, more than 
in the acute form, the intestinal tube being irregularly dilated and con- 
tracted, and its mucous lining altered in color, thickness, etc., according to 
the portion invaded by the disease. The essential primary feature of chronic 
catarrh is the increase and persistence of cell-accumulation in the areolar 
connective tissue of the mucous and sub-mucous layers. Atrophy of the 
wall of the intestine supervenes upon chronic catarrh in eighty per cent of 
the cases, its most frequent seat being the caecum. Lardaceous degener- 
ation of the mucous membrane may also follow. Pneumonia, pleuritis and 



The Life Insurance Examiner. 



59 



cerebritis .are frequent complications. Symptoms. — When chronic catarrh 
succeeds the acute form, there is amelioration of the symptoms and appar- 
ent recovery for a time. 

Any unusual fatigue or excess in eating brings on the diarrhoea again. 
The stools average from four to eight a day, and consist of fluid, mucus, 
and semi-solid faecal matter, being voided early in the day. Constipation 
may alternate with the diarrhoea. There is emaciation, a dirty gray com- 
plexion, debility, a tense abdomen, not sensitive to pressure. The one 
symptom indicative of atrophy is considered by Nothnagel to be the pass- 
age of one soft, unformed stool once a day, which shows that there is no 
increase of peristaltic action. 

Rejection should be the decision in ninety-nine out of a" hundred of 
these cases. In rare instances postponement for a time may demonstrate 
complete recovery. 

Chronic Dysentery. 

Dysentery, or bloody flux, is an inflammation of the mucous and mus- 
cular coats of the large intestines. Varieties of Dysentery. — Acute, which is 
usually epidemic or sporadic ; chronic, typhus, bilious, malarial, ulcerative, 
strumous and tubercular. Pathology. — The type of inflammation is usually 
diphtheritic, the mucous membrane is infiltrated with fibrinous exudation, 
which brings about malnutrition and sloughing in severe cases. 

Causes. — It is supposed to be a specific, infectious, contagious disease, 
depending upon a germ which has not as yet been demonstrated, most 
common in hot countries, and among human beings crowded together, as in 
the case of soldiers. It occurs in the summer and autumn, and may be 
caused by a certain blood poison, as in purpura, cholera, certain fevers, 
ague, syphilis, etc. Bad drinking water, impure air, bad hygiene, exposures, 
etc., are also pregnant causes. The disease is spread from the contagion 
of the stools, which should always, therefore, be immediately disinfected. 
Symptoms. — It is associated with chronic diarrhoea. The patient suffers 
from distressing tenesmus ; the stools are frequent, semi-faeculent, small, 
bloody, slimy, offensive and mixed with pus, mucus and cast-off epithelium, 
and are frequently jelly-like or green in color; alvine discharges, griping 
pain, emaciation, prostration, etc. 

Rejection- — No candidate subject to chronic or recurring dysentery 
is eligible for insurance. 

Intestinal Worms. 

Varieties. — Taenia, or " tape" or " chain-worm," of which there are 
three varieties, usually found in the small intestine ; ascaris lumbricoides, or 
round worm found in the intestines and stomach ; oxyuris, or thread 
worm found in the rectum ; trichocephalus dispar or " whip-worm," found 
in the large intestine and caecum. Symptoms — Frequently no symptoms 
appear, but as a rule there are abdominal pains, nausea, vomiting, saliva- 



The Life Insurance Examiner. 

tion, diarrhoea, dilatation of the pupils of the eye. convulsions, intestinal 
obstruction from the round worms, pruritus am, and a constant desire to 
defecate. 

Posm !)NEMENT. — In case of tape-worm, postpone for six months after 
the receipt of a certificate from the family physician that the parasite is 
wholly expelled.* 

Habitual Constipation. 

Constipation is denned as a condition in which there are infrequent or 
incomplete alvine evacuations, leading to retention of faeces. Causes.—* 
Local causes include constriction of some part of the large intestine, col- 
lections of scybala or concretions, pressure on the rectum from some tumor, 
uterine enlargement, hypertrophied prostate, etc., enfeebled muscles of 
defaecation. atonic condition of the intestinal muscular fibres, pain in the 
pelvic viscera, paralysing the nerves of the intestine, etc. Genera/ Causes. 
— 7.: actional sluggishness, as in the lymphatic temperament, anaemia, 
amenorrhcea, sedentary habits, mental overwork or worn*, abuse of aperi- 
.gard of regular time for going to stool, abuse of alcohol, tobacco, 
coffee, tea, or opiates, and errors of diet. Constipation is also a prominent 
symptom in diseases of the stomach, liver, heart, or nervous system, in dia- 
betes, lead poisoning, etc. It may cause haemorrhoids, strangury, menstrual 
disorders, apoplexy, dyspepsia, palpitation, dispncea, vertigo, headache, etc. 

I 5T1 NEMENT is advised in habitual constipation : in extreme cases 
dependent on serious disease, rejection. 

Intestinal Colic. 

L. — Intestinal colic or enteralgia is the term used to express 

all painful affections of the intestinal tract, caused by irritation of the 
peripheral extremities of the nerves in the intestines, but not coupled with 
inflammatory or structural changes. Varieties. — The most common ones 
are lead, flatulent, and bilious colic. Causes. — In the middle and lower 
part of the abdomen, from organic disease of the ganglia and plexus of 
the sympathetic nerves ; from mesenteric neuralgia in females ; from 
worms, unripe fruit, undigested food, accumulations of faeces, obstinate 
constipation ; from fright, anger, cold ; from affections of adjacent organs, 
such as a morbid condition of the stomach, liver, kidneys, bladder, testicles, 
uterus, ovaries, etc., and from an abnormal state of the blood. Symptoms. 
— Pain over the whole abdomen of a tearing, paroxysmal character, jactita- 
tions, an anxious and distorted countenance, small and hard pulse, nausea, 
vomiting, desire to defecate, etc. Pressure on the abdomen gives relief. 

ACCEPTANCE is advised in all temporary cases of intestinal colic, ex- 
cept when it is recurrent, and depends on a serious condition, in which 
case rejection should be the rule 



The Life Insurance Examiner. 161 

Flatulent Colic. 
>, Flatulent colic occurs from the distention of the intestines with gas. 
Symptcuns. — Tympanitic abdomen, severe pain, cold sweat, anxious face, 
nausea, vomiting, etc. 

ACCEPTANCE. — This form is usually temporary, and does not debar 
from insurance. 

Lead Colic. 

Causes. — Lead colic is caused by drinking water impregnated with lead 
from lead pipes, or by the occupation of painting or mixing colors, the lead 
poison being absorbed into the system. Symptoms. — The attack is usually 
preceded by the symptoms of lead poisoning. Repeated attacks render 
the subject more susceptible. Lead poisoning may assume a chronic form, 
inducing a cachexia, which lasts indefinitely unless the cause is removed, 
and is expressed by general malnutrition, sallow skin, palsy, impairment of 
special senses, Bright's disease, epilepsy, imbecility, etc. The pain of the 
paroxysm is severe, extending to the back and extremities. Other signs 
of lead poisoning are, a blue line along the gums, bad breath, a sweet taste in 
mouth, constipation, retraction and hardness of the abdomen. 

REJECTION. — Must be imposed, unless the applicant changes his occu- 
pation, and shows complete recovery. 

Hepatic Colic. 

Pathology. — Hepatic or bilious colic ; the painful passage of gall-stones 
from the gall-bladder along the duct to the intestine, gives the name to this 
affection, which is the most serious type of colic. The gall-stones are gener- 
ally composed of cholesterin and biliverdin, bile pigment and lime phosphate 
or carbonate. They vary from the size of a pea to that of a hen's egg and 
may be rough or smooth. Ulceration may be produced and consequent 
peritonitis, or the walls of the gall-bladder may be thickened, undergo cica- 
tricial contraction and finally cause atrophy of the gall-bladder. Suppura- 
tive hepatitis is occasionally produced. Causes. — Exciting causes, from for- 
eign bodies in the gall passages around which the concretion is formed ; 
from excess of chalk in the bile, due to drinking hard water which con- 
tains too much lime ; from lack or decomposition of taurocholic acid ; accu- 
mulated secretion of bile ; excess of cholesterin and coloring matter. 

Predisposing Causes. — Advancing age, female sex, sedentary habits, 
habitual constipation, excess of food or drink, cancer of the liver or stomach, 
catarrh, etc., cf the gall-bladder or ducts, interfering with the escape of 
bile. 

Symptoms. — Begin suddenly and unexpectedly. Pain griping and in- 
tense, localized midway between the navel and the border of the ribs on 
the right side and radiating over the abdomen, shooting towards the right 
side and through to the back ; the patient lies doubled up, pressing the 



162 The Life Insurance Examiner. 

hands to the abdomen ; cool skin, distorted face, vomiting, convulsions, ex- 
haustion ; the faeces may be colorless from lack of bile, there is sometimes 
slight jaundice, etc. 

REJECTION — Recurring attacks of biliary colic, even though the inter- 
missions are healthy and the applicant seems to be a fair risk, should reject. 

Piles. 
(See " Haemorrhoids," in section on Diseases of Blood Vessels, Part III.) 

Hernia and Fistula in Ano. 
(See " Physique, " Part II.) 

Diseases of the Liver. 

The liver is a most important organ for the consideration of the Life 
Insurance Examiner, and he should be familiar with all the symptoms which 
would lead the physician to suspect either functional or organic disease of 
this gland. 

Functional Disorders of the Liver. 

Dr. Murchison's arrangement of the functional disorders is chosen, 
because it is succinct and comprehensive. The functions are summarized 
under three heads : 

(i.) The formation of glycogen, which contributes to the maintenance 
of animal heat and the nutrition of the blood and tissues. (2.) The de- 
structive metamorphosis of albuminoid matters, and the formation of urea 
and other nitrogenous products, subsequently eliminated by the kidneys, 
changes which also maintain animal heat. (3.) The secretion of bile, a large 
portion of which is reabsorbed, assisting in the assimilation of fat and other 
elements, whilst a part passing into the intestines stimulates peristaltic 
movements and delays decomposition. 

Causes of functional disorders ; some of them are secondary to organic 
disease of the liver, or of the thoracic and abdominal viscera, fevers, malaria, 
etc. Among the causes of primary disorders, errors of diet and excessive 
use of alcoholic stimulants are the most important. Other causes are, 
habitual excess in eating rich and fatty articles of food, such as soups, 
entrees and pastry, excess of sugar, sweet new wines, liqueurs and malt 
liquors, neglect of physical exercise, hot climates, bad air, depressing mental 
and emotional influences, etc. 

Disorders of the Glycogenic Function. 

These come under the head of " Diabetes." which will be described in 
the next section on the urinary organs. 



The Life Insurance Examiner. 163 



Disorders of the Metabolic Function. 

The views of Dr. Murchison in regard to faulty albuminoid disintegra- 
tion are here advanced. Disorder in this process results in the non-conver- 
sion of albuminoid matter into urea, and the production of lithates and 
lithic acid, causing that abnormal state of the blood called lithaemia. The 
worst effects of this lithaemia may be delayed for a time by elimination from 
the kidneys and bowels. The deposits appear in the urine, especially after 
excesses in eating and drinking, and in persons of the gouty habit. In due 
time, when these morbid products fail to be eliminated from the body, their 
excess in the blood gives rise to various distressing symptoms, such as epi- 
gastric oppression, flatulent distention of the stomach and bowels, heartburn, 
acrid eructations, weakness, drowsiness, catarrh, palpitation, headache, ver- 
tigo, ill-temper, hypochondria, etc. Gout is associated with these symptoms. 
Urinary calculi are often caused by lithaemia, and their treatment should be 
directed to the relief of the liver disorder. Biliary calculi are also the result 
of functional disorder of the liver, and are associated with lithaemia and 
gout. Local inflammations and fevers are promoted by this disorder, as 
well as some skin diseases, like eczema, psoriasis, lichen and urticaria. 
Acute and chronic diseases of all kinds are more likely to set in if the blood 
is thus contaminated. 

Disorders of the Biliary Function. 

(1.) Excessive secretion of bile is characterized by bilious diarrhoea, 
copious fluid evacuations, abdominal griping, nausea, vomiting, fever, 
headache, high colored urine. This condition is generally occasioned by 
congestion of the liver. (2.) Deficient secretion of bile is marked by the 
ordinary dyspeptic symptoms — furred tongue, loss of appetite, flatulence, 
costiveness, pale and offensive stools, sallow or jaundiced skin, dark col- 
ored urine, loaded with lithates, etc. 

POSTPONEMENT.— These functional disorders of the liver, when prim- 
ary and present at the time of examination, require postponement ; when 
secondary to organic disease rejection is, of course, necessary. 

Congestion of the Liver. 

Definition. — Congestion, or hyperaemia of the liver, is a uniform enlarge- 
ment of that organ, caused by over-distention with blood, due either to me- 
chanical obstruction of the return of blood to the heart, or to excessive influx 
of blood from the portal vessels. It is attended with a sense of fullness and 
oppression in the epigastric and right hypochondriac regions, a dusky and 
sometimes jaundiced complexion, and it results, if not relieved, in organic 
disease of the liver. Causes of active congestion are excesses in eating and 
drinking, especially in persons of sedentary and indolent habits. There is 
always a determination of blood to the liver during meals. Sub-tropical 



164 The Life Insurance Examiner. 



and tropical climates induce this condition unless habits of extreme temper- 
ance are observed. A chill may induce active congestion, so also may- 
injuries to the liver, suppressed menses in women, and any of the fevers, 
especially in hot climates where hepatic diseases are common. 

Passive or mechanical congestion or hyperemia is due to obstruction 
to the return of blood through the hepatic vein and inferior cava to the 
heart, as from organic or valvular disease of the right heart, and obstructed 
circulation in the pulmonary arteries from lung diseases, to diseases of 
the left heart, or pressure of aneurismal and other tumors upon these 
passive vessels ; weakness of the heart's action tends to induce this blood 
hepatic congestion. Symptoms. — Are characteristic enlargement of the 
liver, as indicated by the methods of physical diagnosis, tenderness on 
pressure in acute cases ; the enlargement is greatest in passive congestion ; 
a sense of fullness and oppression in the region of the liver, dyspepsia, 
nausea, vomiting, bilious diarrhoea, sallow skin, and in some cases jaun- 
dice; urine high colored and loaded with lithates, etc. Hepatic con- 
gestion, common to hot climates, often ends in chronic enlargement and 
organic disease. The symptoms which mark this form are anaemia, a pecu- 
liar cachexia, sallow skin, weak circulation, coldness of the extremities, ner- 
vous disturbances, dyspepsia, headache, constipation alternating with diar- 
rhoea, etc. 

Added to the symptoms of primary passive congestion of the liver, are 
those indicating the disease of the heart or lungs, on which it may depend. 
Ascites is often a late symptom. 

POSTPONEMENT. — Scrupulous care is required m determining the im- 
port of symptoms pointing to hepatic congestion. If the condition proves 
to be temporary and unassociated with organic disease, the applicant is 
eligible for insurance after due probation and a satisfactory re-examination. 
Reject all doubtful cases and cases of chronic enlargement. 



Enlargements of the Liver. 

The principal hepatic enlargements are associated with the following 
diseases of the liver: (1.) Congestion or hyperaemia. In chronic cases 
and in passive congestion from obstructed circulation, the increase of size 
may be great. (2.) Obstructien of the bile ducts. (3.) Abscess. (4.) Hy- 
datid disease. (5.) Simple hypertrophy, from increase in the number and 
size of the hepatic cells, causes a painless enlargement, (6.) Fatty degen- 
eration causes moderate painless enlargement. (7.) Albuminoid degenera- 
tions often cause great enlargement, second only to that of malignant 
disease and passive congestion. (8.) Malignant disease finally causes great 
increase of size. (9.) Cirrhosis, first stage. 

CONTRACTION of the liver occurs in cirrhosis, atrophy and often in the 
first stage of malignant disease. 



The Life Insurance Examiner. 165 



Fatty Degeneration. 
% Fatty degeneration of the liver is attended with painless enlargement 
and occurs among persons of indolent and luxurious habits, and in connec- 
tion with phthisis and other wasting diseases. Varieties. — (1.) A deposition 
of superfluous fat in the liver cells — the fatty liver of Frerichs. (2.) Dis- 
turbed nutrition of the liver cells by disease of the parenchyma, which 
causes retrograde metamorphosis in the cells. Causes. — Excessive nourish- 
ment and lack of exercise, causing excess of hydrocarbons ; excess in the 
use of stimulants, retarding tissue metamorphosis ; tuberculosis of the 
lungs, preventing the oxidation of hydrocarbons, which become fat ; tuber- 
culosis of the bones or intestines; obesity ; excess of fat in the blood or the 
ingestion of too much cod liver oil. Symptoms. — Debility, gastric and in- 
testinal catarrh, diarrhoea, etc. Physical Signs. — Fullness of the abdomen, 
absence of ascites and enlarged surface veins ; painless, smooth, soft en- 
largement, with thick edges, etc. 

REJECTION. — When this condition is diagnosed the applicant must be 
rejected. 

Amyloid Degeneration. 

Amyloid, lardaceous or waxy degeneration of the liver is due to the 
deposit of this cellulose substance within the liver cells and in the walls of 
the hepatic vessels. Causes. — It occurs in advanced cachexia from scrofu- 
lous, syphilitic and wasting diseases ; from mercurialism, caries of bone, 
tedious suppurative processes, tuberculosis, malaria. Similar degeneration 
of the spleen and kidneys usually coexists. 

Symptoms. — There is a painless enlargement of the organ greater than 
that of fatty liver ; the surface is smooth; ascites is present in some cases, 
due to cachexia and portal obstructions ; the skin is pale. 

Rejection is imperative. 

Cancer of the Liver. 

Cancer of the liver is generally of the medullary variety. It may be 
circumscribed, or diffused among the liver cells, with no line of demarkation. 
Pathology. — In the circumscribed variety the tumor is rounded and lobul- 
ated. The tumors are either solitary or innumerable, from the size of a cocoa- 
nut to that of a pea, giving a rough, nodulated feeling to the surface of the 
organ. When the medullary cancer softens, there is danger of general 
peritonitis or hemorrhage. 

In the diffuse variety, or infiltrated cancer, the liver becomes a white 
cancerous mass, atrophy and fatty degeneration of the liver cells take 
place, leading to obliteration of the blood vessels and gall ducts. Alveolar 
or gelatinous cancer may extend to the parenchyma of the liver from other 
organs, and transform it into a shapeless mass. 

Causes. — It is generally due to a cancerous diathesis, occurs principally 



::: The Life Insurance Examiner. 

in males, and is usually preceded by cancer of some other organ. Symp- 
toms. — Cachexia, dyspepsia, emaciation, tumor, pain on pressure, and disten- 
tion of the superficial abdominal veins from portal obstruction ; the liver is 
indurated and nodulated, ascites is generally present late in the disease, etc. 
Rejection. — Insurance is impossible. 

Hydatids of the Liver. 
These formations most frequently occur in the right lobe of the liver. 
and may reach the size of a child's head. Pathology. — The capsule of the 
tumor is adherent to the adjacent tissue and is firm, fibrous and yellowish- 
white in color. Within the capsule is the cystic layer of the mother cell, 
which contains a strong saline fluid full of thousands of daughter cells. 
Causes. — From ecchinococci entering the hepatic lymphatics, blood vessels 
or bile ducts, and there developing. Symptoms. — Sense of fullness and 
pressure, a lobulated and usually large tumor. Jaundice, ascites, enl^ 
spleen, gastric and intestinal hemorrhage may occur. 
ECTION without exception. 

Cirrhosis of the Li. 

Cirrhosis or interstitial hepatitis is characterized by an excessive con- 
nective-tissue development. It is also called granular, hobnailed or gin-drink- 
ers' liver. Pathology. — First Stage, depending on hyperemia and connect- 

: issue cell-proliferation. The liver is uniformly enlarged, firm, tough, 
smooth, and with rounded edges. Second Stage — The cell growth is organ- 
ized into new connective tissue. The liver is smaller, the surf :-. 
puckered and the edges are sharp. Third Stage — The new connective 
tissue contracts and produces atrophy of the liver tissue from degeneration 
caused by pressure on the blood-vessels. The organ is still smaller 
surface feels as though studded with hobnails, and the edges are sharp. 
Causes. — Alcohol, taken on an empty stomach, which passes directly into 
the blood and to the liver, causing irritation of tissue and new cell- 
growth ; syphilis, inherited tendency to cancer, gout, etc. 

Symptoms. — First Stage. — Sense of fullness and pressure, pain on pres- 
sure, liver increased in size and smooth, portal obstruction, etc. Second 
Stage. — Liver decreased in size, firm and hobnailed, diminished area of dull- 
ness; enlarged spleen, etc Later Stages. — Ascites, enlarged abdor: : 
edema of the legs, etc 

Rejection invariably the rule. 

Jaundice. 
Varieties. — Hepatogenous, in which there is obstruction to the bile- 
ducts. Hematogenous, or non-obstructive, when alteration occurs in the 
blood-pigments, staining the tissues like absorbed bile Causes. — Hepato- 
genous obstructive variety, affecting the common bile-duct: Congenital defect 



The Life Insurance Examiner. 167 

in the duct, extension of catarrhal inflammation from the intestine, calculus 
in the duct, foreign bodies, worms, stricture of duct, pressure from without 
by tumors or enlarged lymphatics. Affecting the radicals of the bile-ducts : 
Cancer, hydatids, abscess, cirrhosis, gummata, tubercle, hyperemia, inflamma- 
tion of the capsule of the liver. Hematogenous Variety. — Blood poisons, ma- 
laria, poisoning by antimony or phosphorus, snake-bites, pyaemia, septicaemia, 
anaesthetics ; hypersecretion of bile, acute yellow atrophy, fevers, pneumo- 
nia and mental emotions; it may be secondary to the hepatogenous variety. 

Symptoms. — Hepatogenous Variety. — Liver and gall bladder enlarged, 
urine colored brown, then green ; faeces colorless, skin jaundiced, emaciation, 
itching, etc. Hematogenous jaundice is marked by nervous disturbances, 
irregular and intermittent cardiac and pulse-beats, the urine and faeces are 
more normal in color, but the urine contains albumen. 

POSTPONEMENT is required until a sufficient interval has elapsed after 
all symptoms have disappeared. 

Ascites. 

Ascites, or dropsy of the peritoneum, is an accumulation of serous 
fluid from non-inflammatory causes. It is usually due to changes which 
have taken place in the liver, heart, lungs, kidneys or peritoneum, or to 
changes in the blood. Causes. — In the liver: Pressure of abdominal tumors 
on the portal veins, atrophy, cirrhosis causing pressure on the portal vein, 
cancer, waxy liver, enlarged lymphatic glands in the transverse fissure, 
hydatids, abscess, tubercle, gummata and portal thrombosis. In the heart : 
Tricuspid regurgitation. In thelungs: Emphysema, cancer, pleuritic effusion, 
and mediastinal tumors, causing insufficiency of the tricuspid valve. In the 
kidneys : Chronic Bright's disease, producing general hydraemia. In the 
peritoneum: Cancer, tubercle and chronic inflammation. Blood causes : 
Anaemia, hydraemia, chlorosis, purpura and scurvy. 

Symptoms. — Feeling of abdominal fullness, dispncea, oedema of the legs 
and ankles, constipation, scanty urine, etc. 

Physical Signs. — On inspection, distention of the abdomen. On percus- 
sion, when the patient is lying down, tympanitic resonance on top from 
the intestines which float on the fluid, dullness below the level of the fluid. 
Auscultation and shaking give the percussion sound. 

Rejection. — Ascites debars from insurance. 

DISEASES OF THE SPLEEN. 
These diseases are seldom seen by the Examiner ; they comprise acute 
inflammation, hypertrophy, leucocythaemia, lymphadenoma, or Hodgkin's 
disease, lardaceous or albuminoid disease, cancer, hydatids, tubercle, syphi- 
lis, etc. Excessive enlargement of the spleen is associated with malaria 
and diseases of other organs, and these should be sought for whenever 
physical diagnosis demonstrates its presence. 



168 The Life Insurance Examiner. 

REJECTION. — Whenever dependent on or associated with organic 
diseases. And the same may be said in regard to diseases of the pancreas 
when detected. 

DISEASES OF THE GENITO-URINARY ORGANS. 

Acute diseases of these organs are seldom seen among applicants for 
insurance, but their sequelae and the chronic forms are so common among 
all classes of people, that it is obviously the duty of the Examiner to detect 
them whenever present. We take the liberty, therefore, of refreshing his 
memory by stating the leading facts concerning the most important of these 
affections. 

Increasing knowledge and experience enables the physician intuitively 
to recognize many ultimately fatal diseases in their intermediate stages, by 
the appearance of the applicant, which the scientific diagnosis confirms. 

Examination of the Urine. 

The chemical and microscopical examination of the urine is considered 
in the last chapter of Part II. 

Diseases of the Kidneys, 
renal enlargements. 

Location of the Kidneys. — The kidneys are situated in the lumbar 
regions, and occupy the space opposite the two lower dorsal and two 
upper lumbar vertebrae, the right one extending down a little lower than 
the left, the upper border of each lying just behind the last rib. They 
may be either diminished or enlarged in disease, the latter condition 
being alone recognizable by physical diagnosis. Enlargement of the kid- 
neys is caused by nephritic calculi, hydro-nephrosis, pyelitis, cancerous, 
tuberculous and other growths, hydatid cysts, or distention from an ob- 
structed ureter, and it sometimes occurs in Addison's disease of the supra- 
renal capsules. 

Diagnosis. — Palpation, by using both hands, one in front and one be- 
hind, and pressing firmly, reveals the enlargement. 

Percussion. — Place the patient lying down on the chest and abdomen, 
which posture allows the intestines to float upon the fluid accumulations 
within the abdomen and surround the kidneys, giving forth a tympanitic 
percussion note in contrast with the dullness of the kidneys. In this way 
the extent of the enlargement is determined ; but enlargements of the right 
kidney are often mistaken for tumors of the right lobe of the liver, cancer 
of the pyloric orifice of the stomach, faecal distention of the colon, 
tumor of the right ovary, or ascites. In like manner enlargements of the 
left kidney have been confounded with tumors of the spleen, or of the left 



The Life Insurance Examiner. 169 

ovary, and with faecal distention of the descending colon and ascites. 
Physical diagnosis is therefore to be depended on only when it is corrobo- 
rated by the rational symptoms presented. 

REJECTION follows the discovery of any renal enlargement, regardless 
of cause. 

Hydro-nephrosis. 

Definition. — Hydro-nephrosis, dropsy of the kidney, or renal dilatation, 
is a non-inflammatory condition, due to the collection of urine within the 
pelvis and infundibula of the kidney, from obstruction of the ureter. This 
dilatation converts the kidney into a sort of pouch, compressing the gland- 
ular substance of the organ, and often dilating some portion of the ureter. 
The renal substance gradually shrinks, and the kidney may become a multi- 
locular cyst as large as a child's head ; the ureters may attain the size of the 
small intestine, with thickened and convoluted walls. The contents of the 
cyst are watery urine containing salts, blood, pus, epithelium and albumen. 
Causes. — From the pressure of an external tumor ; from closure by calculi 
or mucus, or by inflammation and adhesion of the walls; from stricture of 
the ureters, or dilatation, etc. Symptoms. — A slowly developing, painless, 
fluctuating tumor in the lumbar region. Sometimes the obstruction suddenly 
gives way and a large quantity of fluid is discharged from the bladder. 
These cysts have tough walls and seldom rupture, although containing gal- 
lons of fluid in rare cases. Differential Diagnosis. — From ovarian cysts, 
ascites, hydatids and pyelitis. Between hydro-nephrosis and ovarian cysts : 
In the former the tympanitic colon lies in front of the enlargement, while 
behind in the lumbar region all tympanitic percussion resonance is absent. 
Between hydro-nephrosis and ascites : In the former there is no evidence 
of portal obstruction, and the line of percussion dullness does not change 
when the patient shifts his position, the reverse of which is true in ascites. 
Between hydro-nephrosis and hydatids : The discovery of hydatids in the 
urine will alone differentiate the conditions. Between hydro-nephrosis and 
pyelitis: In the former there is absence of pus in the urine, and the consti- 
tutional symptoms are milder. 

Rejection is always demanded in these cases. 

Pyelitis. 

Pyelitis, or pyo-nephrosis (as it is called when the ureter is obstructed), 
is an inflammation, acute or chronic in its course, of the mucous membrane 
lining the pelvis and calices of the kidney. In the acute variety a muco- 
purulent secretion covers the mucous surfaces, and the epithelial cells are 
destroyed in some places. In the chronic form there is dilatation, and pus 
forms and passes off in the urine, unless the ureter is obstructed, when it 
accumulates in the kidney and constitutes pyo-nephrosis. Compression from 



: _ : 



The Life Insurance Ex 



the pent-up pus destroys the glandular substance of the kidney and often 
causes rupture. In case only one kidney is affected, the other one does 
double duty. Causes. — Calculi or foreign bodies in the kidney ; irritation 
from decomposition of abnormal urine in the pelvis of the kidney; ureth- 
ral stricture or enlarged prostate, by causing retention of urine in the blad- 
der, : extension of the inflammation along the ureters to the 
kidney ; the walls of the ureters then become thiekened and the urine is 
obstructed in its egress, decomposes and sets up suppurative inflam- 
mation in both the kidney and bladder. Other causes are, blood-poisoning, 
acute parenchymatous nephritis with haematuria, overdoses of turpentine or 
cantharic it may com ther diseases or result from exposure 
to cold or dampness. Symptams. — Acute pyelitis : Lumbar pain, shooting 
down the course of the ureters and aggravated by change of position or by 
micturition : the urine is acid and contains mucus, blood and epithelial cells 
from the pelvis of the kidney, its specific gravity is 1.026 or more; it often 
contains albumen, and soon becomes ammoniacal. Chronic pyelitis : Lum- 
bar tumor, deep-seated fluctuation, tenderness on pressure, and dullne 
percussion, associated with cystitis, pus in the urine, etc. In pyo-nephrosis 
the tumor is larger, and large quantities of pus may be evacuated in the 

In peri-nephritic abscess, which is a suppuration of the connective tissue 
surrounding the kidney, the cause is usually traumatic, urinary- symptoms 
are negative, a tumor may point externally, the temperature is lower, and 
the pus is easily aspirated just below the last rib. 

REJECT! \\ — Diagnosis 0: :f these conditions precludes the 

p risibility of insurance. 



Diabetes Insijidvs. 

Diabetes insipidus, polyuria, or diuresis, is the term applied to the 
peisstent scharge of large quantities of clear urine, containing neither 
albumen nor sugar, and of a low specific gravity. It i-s accompanied by 

thirst. —Renal longest ton or atrophy is usually prese 

this bscme complaint, which is supposed to be caused by dilatation of the 
renal capi s from disturbance of the ganglionic nerve supply. It 

may be congenital. In its duration it may vary from a few weeks to years. 

Causes — Shock, blows on the head, cerebral disease or tumors, 
disease of the solar plexus or great splanchnic nerves, mental excitement, 
hysteria, insolation, tobacco, intemperance, exposure to cold, drinking cold 
fluids when over-heated, etc. Sjmpfvims. — L'sually comes >n suddenly; 
frequent micturition, quantity of urine increased often from five to forty 
pints in twenty-four hours, intense thiist, iiy skin, great emaciation and 
debility. It is often incurable when dependent on organic nervous disease. 

Rejection is the safest rule. 



The Life Insurance Examiner. 171 

Diabetes Mellitus. 

Diabetes mellitus, glycosuria or mellituria, is the name applied to a 
group of complex symptoms, the most conspicuous of which is an excess 
of saccharine urine. The disease is associated with derangement of the 
glycogenic function of the liver, with alterations in the nervous system and 
pancreas, while in other cases no structural changes can be discovered. 
Pathology. — Glycosuria can be produced artificially by puncturing or irritat- 
ing the so-called diabetic area of the floor of the fourth ventricle in the 
medulla. This area corresponds with the vaso-motor centre and the roots 
of the pneumogastric, which is the sensory nerve concerned in glycogenesis. 
Section of nervous tissue, or any agency which paralyzes the vaso-motor 
nerves presiding over the tonic contraction of the hepatic blood vessels, is 
capable of producing glycosuria. 

The cause may operate upon the central ganglia, whence the nerves 
emanate, such as the vicinity of the medulla oblongata and upper part of 
the spinal cord, or upon the cceliac ganglia and their branches, including those 
to the pancreas. Or the irritation may be peripheral, and its effects reflex. 
Any irritation involving the peripheral distribution of the pneumogastric 
may, therefore, produce it ; and such peripheral irritation may take its origin 
in the stomach, intestines, liver or any organ to which the pneumogastric 
is distributed. Finally, there is no reason why an inhibitory reflex action 
should not originate in the sympathetic itself. 

Pathologists have found structural changes in the nerve centres of the 
brain, meningitis, apoplectic effusions and tumors, or hyaline thickening of 
the cerebral blood vessels ; pancreatic disease is said to be present in one-half 
the cases of diabetes ; the liver is frequently congested, enlarged and other- 
wise diseased ; the kidneys are often hypersemic and enlarged. Atrophy 
of the testicles and pulmonary phthisis are found not infrequently as 
secondary effections. 

Causes. — A majority of the cases of diabetes cannot be accounted for. 
The disease is most common between the ages of thirty and sixty, and in the 
male sex. It may be due to shock, emotion, mental anxiety, overwork, injury 
or disease of the nervous system, or excesses in eating and drinking ; 
to heredity, malarial and continued fevers, gout, rheumatism, catching cold, 
sexual excesses, etc. Symptoms. — Frequent and excessive urination, inces- 
sant thirst and dryness of the mouth, general malaise, dryness and itching 
of the skin and end of the penis or at the vulva, absence of perspiration, 
nervous disorders, ill-temper, feeling of fatigue and drowsiness, disordered 
vision, loss of flesh, anaemia, headache, vertigo, skin eruptions, boils or car- 
buncles, dyspepsia, irregular appetite, palpitation of the heart, failure of 
mental and sexual powers, the presence of sugar in the urine, etc. (See 
Examination of the Urine, Part II. Sugar.) The specific gravity of the 
urine will generally be over 1.025. 

REJECTION. — Rejection should be the invariable rule. Many cases of 



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The Life Insurance Examiner. 173 

chemical. The mechanical explanation refers the cause to a sudden increase 
of blood pressure, or of the proportion of water in the blood, inducing cere- 
bral oedema from this increased pressure ; but many cases of uraemia show 
no encephalic oedema. One of the earliest chemical theories explained the 
symptoms by the retention in the circulation of urea ; and the latest ones 
impute them to the retention of certain other excrementitious matters in 
the blood. 

Symptoms of Acute Urcemia. — In all the varieties of uraemia the symp- 
toms are sudden in their onset. The Comatose Form. — After headache, 
giddiness, affections of sight, vomiting and delirious excitement, coma is 
rapidly developed ; or it may supervene without such premonitory 
symptoms ; the face is pale, the pupils react slowly to light, firm pres- 
sure on the supra-orbital notch does not disclose consciousness, there is 
a peculiar stertor, unlike the deep snoring of apoplectic coma ; and death 
may supervene, or convalescence, only to be followed by a recurrence. 
Acute uraemic coma is most common in the inflammatory and cirrhotic 
forms of B right's disease. The convulsive form simulates an epileptic 
seizure, or may be unattended by loss of consciousness ; it may affect certain 
groups of muscles and simulate tetanus ; the attacks may be single or there 
may be six or more during twelve hours ; they may be recovered from, or 
may prove rapidly fatal. The convulsive type is common to all forms of 
Bright's disease, but most frequently occurs with the inflammatory and 
cirrhotic varieties, the latter being frequently ushered in with convulsions 
as the first symptom. 

Other types of uraemia are the delirious, in which a restless delirium 
replaces other symptoms ; the mixed, in which coma and convulsions co- 
exist ; the dispnoeic, in which there is sudden loss of breath, without cor- 
responding physical signs in the lungs or heart ; and the articular, a rare 
form, resembling rheumatism. Differential diagnosis of acute uraemic coma 
from hemiplegia with loss of consciousness may be made by the absence of 
paralysis of one side, the character of the breathing, and by the urinary 
analysis ; of the convulsive type from epilepsy, by the absence of the initial 
cry, corpse-like pallor, one-sided convulsions, and turning in of the thumbs 
on the palms of the hands, and by the preservation of reflex irritability which 
is lost in true epilepsy; by the invariable presence of albumen in the urine. 
From opium poisoning by the equal contraction of the pupils and by the 
results of an examination of the urine. From belladonna poisoning, by the 
condition of the pupils and the urine. In hysterical convulsions the patient 
falls with a cry into a tetanic or cataleptic condition, the limbs jerk irregu- 
larly, the breathing is spasmodic and choking, there is no lividity of the 
countenance, and the pupils, pulse and temperature are normal. Examina- 
tion of the urine settles the diagnosis. 

Symptoms of Chronic Urcemia. — This comes on gradually, and attracts so 
little attention, that it may sometimes be first observed in the examining 



: -_ The Life Insurance Examiner. 

room of a life insurance com; any Aad in view of that contingency 
Medical Examiner should be familiar with the subject of uraemia in a 
phases. At first there are constantly recurring ; ; f listlessness, drowsi- 

ness* headache, insomnia, peculiar pallor of the fac ess of movements 

and speech, dimness of sight, and ringing in the ears ; later are observed 
cedema under the eyes, then of the ankles extending upward, and general 
anasarca; there is more or less torpor, the patient talks indistinctly when 
aroused, the lethargy deepens into coma with muttering delirium, con_ 
vulsions, 5 s tendinum, and twitching of the facial muscles, then f . 

cedema of the trous inflammations of the endocardium and meninges 

of the brain if death delays. This is a common mode of termination of 
chronic Bright's disease. There is, of course, albumin in the urine. 
Rz :\ — Rejection is imperative. 

Albuminu: 
Albuminuria is a condition characterized by the presence of albumin 
in the urine. Other albuminous matters, not true albumins, may be present 
in haemi aturia, pyuria, spermatorrhoea, etc. 

= ee Chemical Examination of the Urine, Part II., Albumin. 
Causes. — Blood changes, such as occur in periodical and eruptive fevers, 
eral fever, diphtheria, gout, rheumatism, etc.; obstructions in the 
renal cir: from pneumonia, emphysema, valvular disease of the 

heart, weak heart, kidney c * gravid uterus, abdominal tumors, 

etc poison ; :ohol, lead, mercury-, iodide of potassium, 

canth arsenic, chlorate of potash, etc. Abstinence from salt or a sole 

diet of e :.:d to produce albuminuria. 

PatJwlogy. — There are two kinds of albuminuria : rue aibumin- 

iu which serum-albumin appears in the urine : 12.) false albuminuria, 
in which some other albuminous body is found there. True albuminuria is 
caused by some change in either the circulation or structure of the kidney, 
for serum-albumin is not excreted by the healthy kidney. There are two 
kinds of alteration in renal circulation which produces albuminuria: (a.) In- 
creased pressure of blood in the renal arte: increased pressure in the 
renal veins, which is the more common cause. V :>n of the 
kidney is produced by obstruction to the flow of the venous blood 
from the pressure of a tumor, or of the pregnant uterus, upon the renal 
veins or upon the vena cava ; from disease of the liver obstructing the vena 
cava ; or from disease of the heart or lungs, such as tricuspid or mitral 
regurgitation, or chronic bronchitis and emphysema. Temporary albumin- 
uria, observed after cold bathing, etc., is due to venous congestion, and the 
albuminuria associated with nervous liseases is probably caused in the 
same way, rather than by direct nervous action upon the kidney itself. In 
false albuminuria the albuminous bodies pass through the kidney without 
there being any alteration either in the circulation or in the structure. These 



The Life Insurance Examiner. 175 

albuminous bodies are haemaglobin, egg albumin and Bence Jones' albumin. 
Haemoglobin appears whenever blood is present in the urine ; egg albu- 
min, when some portion of it fails to be digested in the alimentary canal 
and is absorbed unchanged and excreted by the kidneys. Bence Jones' 
albumin is very rare, and is found in the urine of persons suffering from 
osteo-malacia. It is almost identical with hemialbuminose, which is one of 
the products of imperfect digestion, when these bodies do not undergo the 
regular transformation in the liver and alimentary canal. Symptoms. — 
Albumin may be present in the urine without exciting any symptoms what- 
ever, but its continuous loss leads to anaemia and certain changes in the cir- 
culation, which result in the following symptoms : A pasty complexion, dry 
skin and tendency to oedema of the cellular tissue, especially under the eyes 
and along the shins ; derangements of digestion, flatulence, nausea, irregu- 
larity of the bowels; nervous disorders shown by muscular weakness, lassi- 
tude, pains and headache ; frequent micturition, palpitation of the heart, etc. 
REJECTION. — It must be decided by repeated examination that albu- 
min is a constant factor, for the continued presence of albumin in the urine 
is sufficient cause for rejection, without the coexistence of any other symp- 
toms. Some companies postpone these cases for a term, according to the 
individual case. 

Renal Congestion. 

Renal congestion or hyperaemia is of ttfo kinds — active, and passive or 
mechanical. (1.) Active congestion enlarges the kidneys. Causes. — Ex- 
posure to sudden changes of temperature ; blood poisons, such as scarlatina, 
diphtheria, typhus and malarial fevers ; irritation of the passages from can- 
tharides, turpentine, nitre, copaiba, etc. It may result from diabetes, 
cholaemia, new growths, traumatism, or cardiac hypertrophy from too forc- 
ible action of the heart. 

Passive or mechanical congestion, especially when associated with 
chronic heart disease, hardens, but does not necessarily enlarge, the kidneys. 
Causes. — Mechanical obstruction to the circulation of any kind, from out- 
side pressure upon the veins, from heart and lung diseases, etc. Symptoms. 
— Decrease in the quantity of urine, increase in its specific gravity, the pres- 
ence of albumin and traces of blood. 

REJECTION. — Chronic renal congestion, or the tendency to it, is a cause 
for rejection of the applicant. 

Bright's Disease of the Kidneys. 

These forms of nephritis, first described by Dr. Bright, are frequently 
brought to the notice of the Examiner, especially in some of their insidious 
stages, when the victim may not be conscious of any danger. The Medi- 
cal Examiner should therefore be conversant with all the manifestations of 



176 The Life Insurance Examiner. 

renal disease, and scrutinize the applicant showing any tendency thereto 
with extra care. 

These diseases develop most frequently between the ages of thirty and 
fifty, and men are more subject to them than women. 

Pathological varieties of Bright's diseases: 

(1.) Parenchymatous nephritis, inflammatory in nature and beginning 
in the uriniferous tubules. 

(2.) Amyloid degeneration, non-inflammatory, and beginning in the 
walls of the blood vessels. 

(3.) Cirrhosis, a peculiar chronic inflammation beginning in the inter- 
tubular tissue of the kidney. 

General symptoms which show the tendency to these various forms of 
nephritis or mark their progress : 

A peculiar harshness and dryness of the skin ; pallor of the countenance ; 
weakness ; lack of energy ; oedema under the eyes or in the lower extrem- 
ities ; headache, blurred vision, spots before the eyes, noises in the ears ; the 
ophthalmoscope may show minute, white exudations on the retina of the eye ; 
dyspepsia, nausea or vomiting, irregular action of the bowels ; symptoms of 
liver disease, of heart disease, such as hypertrophy or valvular lesions, 
of consumptive taint, of former pneumonia, pleurisy or myocarditis, of 
chronic bronchitis or rheumatism, or of former syphilis ; evidences of intem- 
perance or of high living. 

Does the applicant's occupation expose him to sudden changes of tem- 
perature and dampness? Is the climate damp, changeable and along the 
seashore? These are questions which the Examiner should propose to 
himself in weighing the probability of a tendency to Bright's disease. 

Examination of the Urine. — Scanty or excessive amount of urine; 
albuminuria, temporary or persistent ; deficiency of urea ; low specific 
gravity ; casts in the urine, etc. 

Rejection. — Rejection is imperative. 

Parenchymatous Nephritis. 

This is the most common form of Bright's disease, is inflammatory in 
character, begins in the uriniferous tubules, is of short or long duration, 
acute or chronic, and has three stages : 

First Stage. — Of active, catarrhal, croupous or desquamative inflam- 
mation of the uriniferous tubules ; called " acute, desquamative or paren- 
chymatous nephritis." There is more or less intense congestion, with very 
active proliferation and desquamation of the epithelium lining the tubules, 
causing them to become distended and plugged up. 

Second Stage. — Degeneration of the cortical substance, either fatty 
or granular, called the " fatty " or "large, white kidney." The excessive 
engorgement of the first stage may cause rupture of the capillary vessels and 
allow the blood corpuscles to escape into the tubes, wherein fibrin is effused 



The Life Insurance Examiner. • 177 



from the obstructed circulation ; this coagulates in the tubes, and mixes 
with the epithelial cells and blood-corpuscles, forming hyaline material. 
Next the contents of the tubules and the epithelial cells become the seat of 
fatty degeneration, the nuclei of the cells disappear, and the tubules are 
distended with broken-down epithelial cells and fat. 

THIRD Stage. — Atrophy of the kidney. After the fatty degeneration 
of the second stage, cellular elements are developed in the walls of the 
tubules and intertubular tissue. Organization and contraction of this new 
connective-tissue occurs, compressing the blood-vessels, and atrophy of the 
kidney substance follows. The kidneys are smaller than normal, hard, un- 
even and nodular. The tubules become dilated unevenly and form cysts. 
The capsule is thickened and adherent, etc. 

Causes. — The predisposing causes of parenchymatous nephritis are as 
follows : Exposure to sudden changes, alcoholism, sitting in a draught, irri- 
tation of the tubules by excess of excrementitious matter to be eliminated 
by the kidneys while the bowels and skin are inactive, reflex influence of 
the nervous system causing inflammation, reflex influence of the sympa- 
thetic nervous system, renal hypersemia, and inflammation of other organs. 

The exciting causes are blood-poisoning in fevers, scarlatina, typhus, 
diphtheria, measles, pyaemia, rheumatism ; direct irritation of the tubules 
from copaiba, etc. ; mechanical obstruction to the renal circulation in preg- 
nancy, heart and lung diseases; senile decay, pneumonia, and extension of 
inflammation from adjacent organs. 

Symptoms. — For those of the acute form of this disease, see Uraemia, 
in the preceding pages. In the chronic form which commences with the 
acute stage, the following symptoms are developed : General anasarca, w r axy 
countenance, cedema of the feet, hypertrophy of the heart, pulmonary 
oedema, and increased secretion of urine. If the uraemic symptoms subside, 
the patient passes into the third stage of renal atrophy and becomes a con- 
firmed invalid. 

The Urine. — In the first stage of parenchymatous nephritis, the urine 
is scanty and high-colored, of high specific gravity (1.030), and contains 
albumin fifty per cent, epithelial, small hyaline and blood casts and blood 
corpuscles. 

In the second stage the urine is more abundant, not so high colored, of 
low specific gravity (1.005), an d contains albumin about one-third, and fatty 
casts, with oil globules, in addition to those of the first stage. 

In the third stage of atrophy, the urine is pale and greatly increased in 
amount, specific gravity about 1.010, albumin slight in amount, if any; 
casts, fine granular and large hyaline. 

REJECTION. — In all cases rejection is absolute. 

Amyloid Kidney. 
Amyloid, waxy, lardaceous or albuminoid degeneration of the kidney, 
is a non-inflammatory condition and begins as a deposit of amyloid material 



178 ' The Life Insurance Examiner. 

in the walls of the blood-vessels of the kidney. This disease is always 
chronic in its course and generally invades several organs at once. There 
are three stages. First Stage. — Amyloid degeneration of the walls of the 
blood-vessels ; the kidney is slightly increased in size and harder than nor- 
mal; the capsule is not adherent; on section Lugol's solution of iodine 
changes the amyloid material to a dark brown color. Second Stage. — 
Changes in the blood-vessels and uriniferous tubules ; the kidney is very 
much increased in size, the capsule is adherent and the surface is pale and 
smooth. Increase of size is due to increased development of the cortical 
substance, etc. TJiird Stage. — Atrophy of the kidney; the capsule is 
adherent, the surface is uneven, pale and waxy ; the diminution of size is 
due to decrease of both medullary and cortical substances. 

Causes. — Tertiary syphilis, prolonged suppuration, especially in diseases 
of bone, caries or necrosis, suppurative diseases of the lungs, empyema and 
phthisis. 

Symptoms. — Headache, convulsions and coma are rare ; chronic ascites 
or oedema seldom develops ; the progress of the disease is very slow ; there 
are general emaciation, a peculiar cachectic appearance, waxy complexion, 
impairment of the mental faculties, dispncea on exertion, dyspepsia, nausea, 
and oedema of the feet at night; the patient rises two or three times at 
night to urinate; the perspiration has a urinous odor, the urine is greatly 
increased in quantity, and there are diarrhoea and marked thirst ; the spleen 
is enlarged, from the same cause that produces the waxy kidney, as is also 
the liver, which has smooth, sharp edges. 

THE URINE. — Always increased in quantity from forty to one hundred 
ounces in the twenty-four hours, very light color, low specific gravity (1.005). 
Albumin. — Usually only a trace, but if large in quantity, it shows that 
tubular inflammation is set up within the amyloid kidney. Casts. — Large 
hyaline, or granular, or both, not abundant ; when epithelial or fatty casts 
appear, it indicates inflammation of the tubules. 

REJECTION is invariably the rule. 

Cirrhotic Kidney. 

Synonyms. — Renal sclerosis; contracted, small, granular, gouty, ''gin- 
drinkers " and " hob-nailed " kidney, are some of the synonyms of chronic 
interstitial nephritis. 

Definition. — It is due to an increase in the intertubular structures and 
atrophy of all the other tissues. It has three stages : First Stage. — En- 
largement, due to an increase of the intertubular tissue, from connective 
tissue cell-growth. Second Stage. — Organization of this new tissue. Third 
Stage. — Atrophy, due to contraction of the new tissue, producing degener- 
ation from pressure on the blood-vessels. The disease develops slowly and 
insidiously and usually appears between the ages of forty and sixty. 

Causes. — Most common are gout and rheumatism, producing it by the 



The Life Insurance Examiner. 179 

action of their peculiar blood poisons ; lead poisoning, cancerous diathesis, 
malaria, mental strain and syphilis; alcoholism may produce cirrhosis both 
of the liver and of the kidneys. 

Symptoms. — The early symptoms are generally obscure ; these are fre- 
quent micturition, anaemic appearance, weakness and dyspepsia ; ascites 
may not occur until late in the disease, or from cirrhosis of the liver ; there 
are slight oedema of the lower limbs, especially after walking through the day, 
excessive quantity of urine, and great thirst. Nervous Symptoms. — These 
are marked headache, if associated with gout or rheumatism, vertigo, tem- 
porary inability to speak, insomnia, deafness, numbness, cramps, neuralgia, 
chorea and paralysis ate among the more common ; uraemic symptons, con- 
vulsions and coma are more common in this than in any other form of 
Bright's disease, and are usually developed after some mental or physical 
exertion, etc. 

The URINE. — Greatly increased in quantity, and of low specific 
gravity (1.010). Albumn is sometimes, but not always, present :; the casts 
are few and difficult to find, and are usually of the large hyaline variety. 

Complications. — Cardiac hypertrophy of the left ventricle is almost always 
present from obstruction, arterial tension is high, and there is atheroma of 
the walls of the arteries. Mucous inflammations, especially chronic bronchitis, 
alternating with renal and gouty symptoms; uraemic neuro-retinitis of one 
eye and then the other ; hemorrhages from mucous and serous surfaces, 
especially cerebral apoplexy, from degeneration of the cerebral arteries and 
the increased force of a hypertrophied left ventricle, are other complications 
often met with. 

Rejection is peremptory ; and it is necessary for the Examiner to ex- 
ercise the greatest caution to prevent the acceptance of many applicants 
suffering from chronic interstitial nephritis in the developing stage. 

Renal Tuberculosis. 

Tuberculosis of the kidney is a rare disease, and is usually secondary 
to tubercular disease of some other organ, particularly of the lungs. It 
generally occurs between the ages of twenty and forty. Its site, in the 
majority of cases, is the left kidney, and the symptoms are enlargement of 
the kidney, pain in the lumbar region, and frequent micturition. The 
urine is albuminous, and contains blood, epithelium and eventually 
miliary tubercles.. 

REJECTION. — Rejection should be the invariable rule. 

" Renal Cancer. 

Cancer of the kidney is of rare occurrence ; it may be primary, or sec- 
ondary to carcinoma of other organs. The deposits are of the medullary 
type, and appear as circumscribed nodules in the cortical substance. The 



180 The Life Insurance Examiner. 

cancerous tumor may become enormously large, and the disease is often 
associated with cancer of the testicle. Symptoms. — Gradual emaciation, 
lumbar pain, cachectic countenance, an irregular and immobile tumor in the 
lumbar region, and enlarged superficial veins ; the urine is unchanged, or 
there may be albuminuria with haematuria. 

Rejection. — The disease is rapidly fatal, and rejection is imperative. 

New Renal Growths. 

Cancer, miliary tuberculosis, tumors of the intertubular structure, sy- 
philitic gummata, fibroma in the pyramids, lipoma of the capsule, pelvis or 
cortical substance. 

REJECTION. — They will reject when diagnosed. 

Renal Calculi. 

Renal calculi form in the uriniferous tubules of the pyramids, in the 
pelvis of the kidneys, or in the cortical substance, and occur at any age. 

Pathology. — In advanced life the formation of calculi is associated with 
a gouty diathesis and lithaemia, and deposits of the urate of soda are found, 
as described in a previous section ; calculi of carbonate and phosphate of 
lime form also during certain bone diseases. They produce cysts or are 
washed down, and lodge in the pelvis of the kidney. They may obstruct the 
ureters and excite pyelitis, renal abscess, hydro and pyo-nephrosis, or 
parenchymatous nephritis. The nucleus of the calculus may be blood, 
epithelium, grains of pigment, or pus. 

Varieties. — Uric acid in children and young people ; in adult life, 
lime and the triple phosphates. 

Symptoms. — The symptoms are generally pain in the lumbar region, 
and those of renal colic, aggravated by any form of exercise that jolts the 
body, which continue until the calculus passes out with the urine, ceases to 
irritate or becomes encysted. 

Postponement. — One company postpones a case until five years have 
elapsed after the passage of a urinary calculus. The length of postpone- 
ment should depend on the hereditary predisposition and diathesis. 

Rejection. — In all cases where the condition is recurrent or incurable. 

Renal Colic. 

Renal colic, or nephralgia, is caused by the passage of a calculus from 
the kidney along the ureters to the bladder. Symptoms. — The onset is 
sudden ; there is intense pain in the affected region, radiating downward 
to the bladder, testicles, end of the penis and thighs ; the patient shrinks 
and writhes with pain, there is violent and painful vomiting ; the counte- 
nance is anxious, pale and moist, pulse small, extremities cold. The urine 



The Life Insurance Examiner. 181 



may be suppressed or scanty, high colored or bloody, and often causes 
pain when it is voided. 

REJECTION. — Recurrent attacks of renal colic reject. 

POSTPONEMENT. — An applicant should be postponed at least two 
years after the last attack. 

Addison's Disease of the Suprarenal Capsules. 

REJECTION. — It causes the characteristic peculiar bronzing of the skin, 
and rejects the applicant. 

Bladder and Generative Organs. 

chronic cystitis. 

Causes. — It generally results from retained urine due to the urethral 
obstruction of permanent stricture or enlarged prostrate gland, or to some 
obstacle to the free egress of urine, like vesical calculi, growths in the 
bladder, paralysis, atony ,and over-distension ; from disease of a nerve 
centre ; from disease of adjacent organs ; certain affections of the kidney, 
and from altered urine, lithaemia, catarrh, etc. Symptoms. — Dull pain and 
a sense of fullness in the hypogastric region, frequent and painful micturi- 
tion. The urine is cloudy, and contains mucus, blood, pus and phosphates. 

Rejection.— Its presence rejects absolutely. 

Stone in the Bladder. 

Urinary calculi vary in size from sand-like grains to stones the size of 
a small orange. 

Symptoms. — Severe paroxysms of pain in the bladder, perineum and 
glans penis, aggravated by exercise ; frequent micturition, sometimes in- 
continence of urine, and a feeling that the bladder cannot be emptied. 
The urine, often thick with soapy mucus, may contain blood and pus, and 
the act of urination may be suddenly stopped by pressure of the stone 
against the neck of the bladder. Tenesmus and prolapse of the rectum 
are common. Discovery of the stone with the exploring urethral sound 
will confirm the diagnosis. 

Postponement. — Its presence rejects during continuance and convales- 
cence, but unless the hereditary predisposition and diathesis are strongly 
marked, the passage of a small calculus does not affect life insurance per- 
manently. One company postpones for five years after the passage of 
a urinary calculus. 

Prostatitis and Enlarged Prostate. 

Rejection. — If sufficient to retard the extrusion of urine, rejection is 
absolute, and all cases should be postponed until it is certain that the con- 
dition is merely temporary. 



1 82 The Life Insurance Examiner. 

Spermatorrhcea. 

Acceptance. — Occasional spermatorrhcea and nocturnal emissions 
need not reject, unless associated with serious constitutional or local disease. 

Masturbation. 

The Medical Examiner should be quick to detect impairment of the 
constitution and physique from this common habit, as well as from sexual 
excess, and report the facts to the home office — even if the case be other- 
wise acceptable. 

Gonorrhoea. 

In applicants who have had gonorrhoea, examine carefully for perma- 
nent stricture of the urethra and symptoms of gonorrhceal rheumatism. 
If any evil effects remain they should be taken into account in rendering 
an opinion. Stricture either postpones or rejects according to the gravity 
of the case. Gonorrhceal rheumatism postpones for two or more years 
after the last attack. If it is of the recurrent variety it absolutely rejects. 

Urethral Stricture. 

POSTPONEMENT. — Postpone all of these cases, whether spasmodic or 
organic, until the condition is relieved and all secondary symptoms have 
disappeared. 

Urinary fistula must also be cured before acceptance. 

Chancroids and Buboes. 

POSTPONEMENT. — Postpone, until they and the conditions upon which 
they depend, are entirely cured. 

Syphilitic Chancre. 
Rejection. — See Syphilis. 

GENERAL HEALTH RECORD. 

(See " Instructions to Medical Examiners," Part I.) 

Previous Serious Illness. 

Some companies propound the question— " Has the applicant had any 
serious illness, injury, deformity or amputation during the past seven 
years ; "' The most recent diseases the applicant has suffered from should 
be recorded first, then those more remote, and the Examiner should note 
whether any previous illness has served to develop any inherited tendency 
to disease, or deteriorated the functional or organic health of any organ. 



The Life Insurance Examiner. 183 

Mechanical or Surgical Injury. 

The effects of any accident, injury or surgical operation upon the per- 
son of the applicant should be thoroughly investigated. Ascertain if 
malignant or tuberculous disease, caries or necrosis, etc., were either the 
causes or complications of any surgical operation ; and notice whether 
there are signs of exhausted vitality. 

Amputations. 

In many instances the amputation of important members and capital 
operations greatly lessen the insurability of a candidate, by impairing the 
original constitution of the individual and his power of resisting future 
disease. One company in cases of amputation above the knee charges 
one-half per cent extra premium. 

Deformities. 

Malformations and deformities, congenital or acquired, should be cause 
for rejection when of sufficient extent to impair locomotion or when they 
present an objectionable or unsighty appearance. The Examiner should 
write a description of the condition, and incorporate it with his report of 
the examination, so that the executive officers can decide intelligently, for 
it often happens that an applicant may be perfectly insurable in all other 
respects and yet present some unfortunate malformation, which would 
debar him from insurance, because in some companies it is not considered 
advisable to insure risks who are noticeably deformed. 

Negroes and Half-Breeds. 

One company charges one-half per cent extra premium rates to negroes, 
pure or mixed blood, residing outside of the tropics, but most companies 
prefer not to insure them at all. 

Previous Insurance or Rejection. 

Previous insurance of a candidate in another or the same company 
must not tempt the Examiner to relax his vigilance. In the lapse of time 
since a previous acceptance the personal habits of the applicant, the devel- 
opment of some hereditary tendency or constitutional disease, or some 
serious illness or accident, may change the condition of the risk, and pre- 
vent insurance. Previous rejection should incite to double vigilance. 

Family History. 
(See " Hereditary Influences," Part I. and Part III.) 

Physical Condition. 
(See " Examination of the Applicant,*' Part II.) 



1 84 The Life Insurance Examiner. 

Small-pox. 

Small-pox or varioloid, if completely recovered from, is rather a 
recommendation than an obstacle to insurance. But the Examiner must 
bear in mind the complications common to that disease, which are inflam- 
mations of the serous membranes, especially pleurisy, pericarditis, pneu- 
monia, bronchitis, consumption, uraemia, nervous affections and bone dis- 
eases, and judge from his examination whether there are any sequelae 
present in any of those organs which may be prejudicial to the risk. 

Vaccination. 

See •'• Physique," Part II. In most companies lack of successful 
vaccination requires a special contract that death from small-pox is not 
insured against, and it is therefore necessary that the fact of a vaccination 

be elicited. 

Scarlet Fever. 

Previous history of scarlet fever, fully recovered from, is also said to 
indirectly improve the risk. In this case the Examiner should be equally 
careful in his search for injurious after-effects. The ordinary complications 
of a case of scarlet fever are consecutively — nephritis, bronchitis, pneu- 
monia, inflammations of serous membranes, ulcerative endocarditis, rheuma- 
tism, suppurative inflammation of joints, diphtheria, suppuration of the 
middle ear, uraemia, anasarca. Hence one must look well to the kidneys, 
urine, middle-ear. throat, heart and general diathesis, before recommending 
the risk. 

Yellow Fever. 

If the applicant has had yellow fever and suffers no evil effects it is a 
recommendation, especially if he resides in the belt where it is endemic. 
It is a miasmatic, infectious, contagious disease, and occurs between forty 
degrees North and twenty degrees South latitude, generally as an epidemic 
in crowded cities or towns along the sea coast. 

(See '• Climate." Part II.) 



PERSONAL HABITS. 

(See " Instructions to Medical Examiners," Part I.) 

Where the personal examination seems to be negative as regards 
the determination of life-expectation, reliable data concerning the candi- 
date's personal habits may decide as to the insurability of the risk, and a 
competent observer can judge approximately whether the applicant is con- 
firmed in habits of physical health. 



The Life Insurance Examiner. 185 

Intemperance. 

> (See " Life Insurance Formalities," " Instructions to Medical Exam- 
iners," Part I., and "Hereditary Influences," and "Diathesis," Part III.) 

The Opium Habit. 

The peculiar cachexia of this habit is unmistakable. It is the absence 
of animal health, the counterfeit of premature old age — wasted muscles, 
shriveled, colorless skin, clammy with perspiration, with the characteristic 
odor of opium, the averted look, contracted pupils, nervous irritability, 
mental and physical lassitude, etc. 

REJECTION. — Actual presence of this chronic habit, as corroborated by 
the evidence of the family physician, or of an intimate friend, always rejects. 

Other Nervous Stimulants. 

REJECTION. — The habitual indulgence in other narcotics and nervous 
stimulants, tending to destroy functional and organic health and shorten 
life, when proven as above, is sufficient ground for rejection. 

Some of the agents used are chloroform, ether, Hoffman s anodyne, 
cannabis indica, chloral, the bromides, cocaine, etc. Tobacco, coffee, tea, 
etc., indulged in to excess, should be classed under the same head and cause 
postponement. 

MEDICAL ADVISER. 

The name and address of the applicant's regular family physician or 
last medical attendant should be written down by the Examiner when it 
is required by the company for whom he is examining. 



FEMALE INSURANCE. 

General Considerations. 

The general suggestions considered heretofore relating to the physical 
and personal examination of the applicant, as well as to the diseases affecting 
life insurance, apply with equal force in the case of a woman ; but we have 
now to notice the subject of the reproductive organs, as a conclusion of 
this part of the work. 

Although some companies decline to write female risks owing to the 
prospective dangers of the child-bearing period, it is only fair to state that 
the female life expectation is about three years more than the male, from 
which statistical data we may safely conclude that the peculiar hazards of 
this epoch are more than counterbalanced by the increased hardships and 
exposure of the male sex. 



1 86 The Life Insurance Examiner. 

In order to overcome this prejudice, the examination of the genito- 
urinary organs should be searching, and placed in contrast with the general 
constitution and personal health of the female applicant. 

Most companies charge one-half per cent extra premium for all female 
risks, prior to the age of forty-eight. 

The differences in anatomical configuration and physique have been 
alluded to in the section on " Physique," Part II. 

Primipar^e. 

Among primiparae the rate of mortality considerably exceeds that of 
multiparae up to the ninth labor, after which the consequent risk increases 
with each succeeding parturition. Primary gestation is more liable to the 
complications of difficult labor, post-partum hemorrhage, puerperal fever, 
convulsions and mania, mammary diseases, miscarriages, etc. 

Postponement. — When the applicant is pregnant for the first time, the 
application must be postponed until she is fully recovered from the effects 
of parturition. 

Multipara:. 

ACCEPTANCE. — Women who have borne children in normal labors, 
without instrumental interference and show no injurious after-effects, may 
be insured. 

Postponement — Postpone all cases of pregnancy; all instances 
where the mother seems, in the judgment of the Examiner, to have been 
bearing children too fast ; and all cases with a history of instrumental 
labors, malpresentations, etc. 

Change of Life. 
Postponement. — There are peculiar dangers connected with the 
climacteric period during the cessation of the function of menstruation, 
when transmitted tendencies are likely to appear suddenly. It is safest to 
postpone such applicants until the crisis is fully passed, unless the candi- 
date is an exceptionally good risk in all other respects, and enjoys perfect 
general health. 

Uterine Diseases. 

Rejection. — All organic diseases and tumors of the uterus or ovaries, 
recurring hemorrhages, etc., when present, positively reject. 

Conditions that Reject. 

A history of repeated miscarriages, malpresentations from deformed 
pelvis or other causes, instrumental labors, post-partum hemorrhage, puer- 
peral diseases, uraemia, etc.; the presence of organic mammary diseases or 
tumors; emaciation and exhaustion during lactation, etc. A history and 



The Life Insurance Examiner. 187 

cachexia that denote liability to the development of inherited taints. See 
" Hereditary Influences," Part III. 

Dropsical effusions, phlagmasia dolens, remarkable varicosity of the 
veins, etc. 

Conditions' that Postpone. 

Chronic metritis or endometritis, subinvolution of the uterus, prolapsus, 
chronic uterine displacements, vesico-vaginal and other fistulae, severe 
lacerations, menstrual disorders, profuse leucorrhoeal and other discharges, 
all reflex disturbances, etc., should postpone until completely cured. 

Menstruation. 

Critical inquiry should be made with reference to the past and present 
performance of the menstrual functions. Has any reported irregularity or 
imperfection in this respect impaired the general health ? Is it a family 
characteristic, etc. 



BIBLIOGRAPHY. 



The principal books used in the preparation of this volume are : 
" The Medical Adviser in Life Insurance," .... Sieveking. 
11 Medical Examinations for Life Insurance," .... Allen, 
" Medical Examination for Life Insurance," .... Levan. 

"Walshe on the Heart," 

" Walshe on the Lungs," ........ 

" Physical Diagnosis," Delafield and Stillman. 

" Physical Diagnosis," - Looniis. 

u Medical Diagnosis," Da Costa. 

" Manual of the Practice of Medicine," Moir. 

»' Dictionary of Medicine," Quain. 

" System of Medicine," Pepper. 

" System of Medicine," ....... Reynolds. 

" System of Surgery," - ----- Holmes, 

11 Encyclopedia of Medicine," Ziemssen. 

u Mortuary Statistics," ... - Various Insurance Companies. 
" The Medical Examiner in Life Insurance," - Taylor. 

etc., etc. 



APPENDIX, 



I.-LEGAL QUESTIONS AS TO THE OFFICE AND EVIDENCE 
OF THE MEDICAL EXAMINER. 

IT is a matter of interest, as well as of importance, to the Medical Ex- 
aminer to understand his legal relations to the applicant and to the in- 
surance companies. Through the courtesy of Mr. John M. Taylor, 
Vice-President of the Connecticut Mutual Life Insurance Company, we are 
enabled to present an abstract of a pamphlet written by him on this sub- 
ject, and for fuller information we refer our readers to the pamphlet itself. 

History of Life Insurance. 

In the year 1610, at Florence, Italy, Giovanni Battista insured the life 
of Sir Knight Brother Ferdinand for the sum of 3000 scudi, the term ex- 
tending from the August Festival at Piacenza of that year to the Feast of 
the Epiphany in 161 1, the premium being three and three-fourths per cent 
of the amount underwritten. The policy was written in quaint mediaeval 
Latin. At that time the Italians were accustomed to call an insurance pol- 
icy a lottery ticket. But the Italian mind, with its love of speculation and 
chance, never kept pace with the practical ingenuity of the Anglo-Saxon. 

This old Florentine policy nearly marks the limit of historic acquaint- 
ance with life insurance as a monetary transaction. The policy is " incon- 
testable " and " indisputable " in every legal sense which can attach to such 
a contract. It is agreed that in the event of the death of Sir Knight 
Brother, the assurers shall not be able to say, offer or accept anything, un- 
less after full payment. It covers natural or accidental death. It grants 
free residence and travel anywhere in the world, by land or water. It has 
no time limit as to its " indisputable " qualities. It is good at issue. It re- 
quires no proof of interest in the life insured. It waives in terms all 
statutes in this behalf, and the claim is payable three days after notice of 
death. The policy was a pure "gamble" by Batista. But the chief inter- 
est in the policy, in this connection, is the fact that it was probably written 
with no reference to a physician, or his opinion. It is a curious fact that 
the first life underwriters reckoned their chance of loss, their real hazard, 



Appendix. 



on death by accident, and excluded death from natural causes. Until the 
companies themselves, with capital at risk, found by experience that they 
could not insure all classes, conditions and ages of men for long periods at 
a given premium, and remain solvent, reference of the risk to a physician 
was seldom made, and it was at a relatively late date that a medical examina- 
tion became a common requirement in life underwriting. In the rapid 
growth of our American life companies all genuine reform in this import- 
ant matter has come of experience. The companies have followed the 
courts in their decisions, and in no respect, perhaps, has development 
been so slow as in the gradual advance of the medical officer to his present 
station of responsibility and honor. 

Typical Agreements 

imposed by life insurance companies. 

The following typical provisions in the printed application for insur- 
ance and medical examination of certain companies mark the limits of the 
recently attempted changes in the Examiner's responsibilities, and invite 
discussion of his real relation to the company and to the insurance contract, 
and of his testimony with some of its limitations : 

" It is hereby agreed : that all the foregoing statements and answers, as well as those 
made or to be made, to the society's Medical Examiner, are warranted to be true, and are 
offered to the society as a consideration of the contract." 

" Does the candidate expressly waive all provisions of law forbidding any physician who 
has attended him from disclosing all information which he thereby acquired?" 

14 1 also agree that all the foregoing statements and answers, as well as those that I make, 
or shall make to the company's Medical Examiner in continuation of this application, are by 
me warranted to be true, and are offered to the company as a consideration of the contract." 

'* Has any answer given by you to any question in this application been made, modified 
or influenced by any explanation or advice of the Medical Examiner, or any other person ? " 

" I hereby declare and warrant — That I hereby waive all personal or statutory rights which 
I may have to object to the testimony of any physician or surgeon, whether consulted by me or 
not, so far as he may have professional or expert knowledge of the facts or information sought 
for by the interrogatories in this application." 

Former Precedents. 

The former relations of Examiners, as set down in law reports and the 
institutional writers of England and America, may be summarized as fol- 
lows : 

(i.) The person whose life is insured, the Examiner and the private referees were regarded, 
to a certain extent, as the agents of the insured party. 

(2.) In making replies the referees are the agents of the party proposing the insurance, 
and their statements are representations made on his behalf, and form part of the contract. 

(3.) The friend's report and that of the medical referee are regarded in law as statements of 
the assured party. 

(4.) If it be proved that the referees knowingly gave false testimonials, the policy shall be 
void. 



Appendix. 



(5.) The medical referee is the agent, in respect to his replies, of the proposer, and the 
latter is responsible for any want of candor or neglect by him. 

> (6.) If the fee were paid to the medical referee by the company, the question would arise 
whether he had not become the agent of the insurers, instead of the applicant. 

See Bunyon's Law of Life Insurance ; Crawley's Life Insurance ; Bliss on Life Insurance; 
May on Insurance. 

Former Court Decisions. 

But it can no longer be successfully argued or maintained, at home or 
abroad, that solicitors, Examiners, referees, or other company representa- 
tives, are agents of the parties who become insured, and when the signifi- 
cant facts are added that, with us, the Medical Examiner receives his 
appointment from the company, acts under its instructions, deals with it in 
all its functions, and is paid by it for its services, it must be assumed upon 
authority that the office or relation of the Examiner to his company is one 
of agency for certain important purposes. And here agency means respon- 
sibility in a broad sense. The Examiner's acts under these new contract 
clauses become his principal's, his company's, acts, and the corporation is 
bound by them within the scope of his authority. That authority now 
undertakes to cover the whole range of negotiation between the applicant 
and the company, and the Examiner is made the sponsor for the truth or 
falsehood, the good or bad faith of the applicant whose statements are 
4< the basis of the contract," and upon whom should always rest the force 
and effect of the warranty, the first and last consequences of misrepresent- 
ation or fraud. 

The courts have defined the powers and duties of the Examiner in 
various cases, but the same decisions often turn upon the competence of 
certain evidence, the admission of medical testimony, or the waiver of rights 
under statutes as to privileged communications, and to avoid confusion 
these questions are treated together in the citations of authorities. 

Note. — In several of the States of the Union, notably in New York, Missouri, Wisconsin, 
Michigan, Iowa, Nebraska and Illinois, there are statutes making the knowledge or information 
derived by a physician from his patient a privileged communication, and, in some of the States, 
the statutes have been construed to cover the information or knowledge derived by the Medical 
Examiner as attending physician and in the matter of making certificates of loss and of testify- 
ing as to the causes of death under life insurance policies. At common law no such privilege 
existed (and the English rule now does not exempt the report of the medical officer, and the 
courts will order its production if the insured makes out a prima facieca.se), and it is, there- 
fore, purely statutory. 

Its significance lies in the fact that if the medical officer is the agent 
of the company for certain purposes, and does the agent's work, when his 
testimony may be most needed to defend his company from fraud, or pos- 
sibly to uphold the integrity or wisdom of his own acts, it may be inadmis- 
sible or incompetent by the intervention of the remedial statutes of privilege. 

For information, the New York statute in this behalf, which served as 
a model for others, is here cited : " A person only authorized to practice 



Appendix. 



II.— AGENTS' REPORT. 

This is the term usually employed to designate that portion of an 
application which embodies the request of the applicant to the company 
for insurance, and is signed by the applicant and attested by the agent 
before the medical examination is proceeded with. 

The following are some of the conditions imposed upon the applicant 
by one of the prominent companies: 

OTHER FORMALITIES, to which the applicant is required to subscribe, 
are as follows — printed on the back of the application : u Subject to the 
charter of said company and the laws of said State, I hereby apply to The 

Life Insurance Company of , for $ , amount of insurance on my 

life, upon the (plan of insurance, either life or distribution). 2. My full 
name. 3. Occupation. 4. Residence. 5. Place of business. 6. P. O. ad- 
dress. 7. If any intention exists of changing residence, or occupation ; 
state in what manner. 8. Place of birth. 9. Date of birth. 10. Kind of 
policy. 11. Premium payable — quarterly, semi-annually, or annually. 12. 
Full name and residence of person to whom insurance is payable. 13. Re- 
lationship to the person whose life is proposed for insurance. 14. If insured 
in this or any other company, give name of company and amount. 15. If 
any proposition or negotiation, or examination for life insurance, has been 
made in this or any other company, or association, on which a policy has 
not been issued, state when and in what company. 

u I hereby warrant and agree not to reside or travel in any part of the 
torrid zone, and not to engage in any specially hazardous occupation or 
employment during the next two years following the date of issue of the 
policy for which application is hereby made, without first obtaining per, 
mission from this company ; and I also warrant and agree that I will not 
die by my own voluntary act during the said period of two years. 

"(The specially hazardous occupations, or employments herein referred 
to, are: Blasting, mining, sub-marine labor, aeronautic ascensions, Arctic 
explorations, the manufacture of highly explosive substances, service upon 
any railroad train, or in switching or in coupling cars, or in any steam or 
other vessel, or military or naval service in time of war.) / also agree that 
all the foregoing statements and answers, as well as those that I make, or 
shall make, to the company's Medical Examiner, in continuance of this 
application, are by me warranted to be true and are offered to the company 
as a consideration of the contract, which shall not take effect until the first 
premium shall have been paid during my life and continuance in good 
health. 

" I certify that I am temperate in my habits, and am, to the best of my 
knowledge and belief, in sound physical condition and a satisfactory sub- 
ject for life insurance. Date, signatures of applicant and a witness." 



Appendix. 



III.— INSTRUCTIONS TO AGENTS. 

> 

It very often occurs that agents call upon the Medical Examiner of the 
locality in which he resides, for information as to the insurability of certain 
candidates whose health record or physical condition present some disquali- 
fying features. To assist the Medical Examiner in this duty, one large 
company* issues the following scheme to its agents for their own inform- 
ation : 

Memorandum of Circumstances Affecting the Assurability 

of Lives. 

In order to save would-be patrons the annoyance of futile application 
for a policy in this society, the following memorandum is offered of some 
of the more commonly occurring circumstances held by the Medical Direct- 
ors to seriously affect life assurability. In practice, the degree and period 
of disqualification are ordinarly as stated, but it is to be understood that 
the company reserves the privilege of accepting or declining at will any 
given proposal. In the case of lives falling within any of the questionable 
categories, correspondence with the Medical Directors is invited before 
formal application for insurance is made. Opinions upon the assurability 
of given lives are always cheerfully furnished. In submitting a case, the 
fullest particulars should be given. 

I. — Permanently Disqualifying. 
i. Any history — past or present — of the following diseases : 



Apoplexy. 

Paralysis of one side of the body (" hemiplegia "). 

Delirium tremens. 



Tertiary or inherited syphilis. 

Cancer, sarcoma, or other " malignant " disease. 



2. A history of attacks, sufficiently numerous to seemingly portend a 
predisposition thereto, of any one of the following diseases or conditions 
(N. B. — Cases falling within this category are passed upon according to in- 
dividual merits) : 



Epileptic fits. 

Sunstroke. 

Articular rheumatism. 

Gout. 

Erysipelas. 

Hemorrhage from the air passages. 



Bronchitis. 

Pleurisy 

Gravel. 

Calculus (urinary or hepatic). 

Albuminuria. 

Hepatic colic. 



In general, any recurring affection of an important organ. 



The Equitable Life Assurance Company of New York. 



Appendix. 



3. The existence of any of the following chronic conditions 



Established extreme leanness. 
Established extreme obesity. 
Humpback (angular curvature of the spine). 
Valvular disease of the heart. 
Enlargement of the heart. 



Considerable pleuritic adhesions. 
Considerable emphysema of the lungs. 
Considerable consolidation of a lung. 
Irreducible hernia. 
Enlarged prostate. 



In general, any pronounced incurable organic affection of a vital organ. 

II. — Temporarily Disqualifying. 

1. The existence of any of the following diseases or conditions disqual- 
ifies for the time being, but yet not necessarily for longer than the period 
of actual continuance : 

An open sore or ulcer of any considerable size. 
Diseased bone ("caries," "necrosis "). 
Fistula (notably fistula-in-ano). 
Purulent discharge from the ear (otorrhcea). 
Habitual cough. 

In general, pronounced derangement of any important organ or function. 

2. The occurrence of any of the following diseases or conditions disqual- 
ifies, not only for the time being, but also for a term after final disappear 
ance, according to the case : 

Articular rheumatism — minimum term of subse- Hemorrhage from the air passages — minimum 



Recurring asthma. 

Pulse-rate over ninety or under fifty per minute. 

Organic stricture of the urethra. 

Stone in the bladder. 



quent disqualification, one year. 

Chancre, not followed by constitutional symp- 
toms — minimum term, six months. 

Secondary syphilis, not followed by tertiary 
symptoms — minimum term, five years after 
last manifestation. 

Albuminous urine — term according to case. according to case 

Saccharine urine — term according to case. 



term, ten years. 
Passage of a urinary calculus — minimum term, 

five years. 
Discharge of a tape-worm — minimum term, six 

months. 
Intemperance (systematic or occasional) — term 



III. — Variously Disqualifying. — (Cases judged individually.) 

1. Death of both parents from consumption ordinarily disqualifies, at 
least during early and middle life, unless the applicant be of robust physique, 
while, at the same time, there were exceptional extenuating circumstances 
attending one or both cases of death. 

2. Death of one parent, or of more than one among brothers and sisters, 
from consumption, ordinarily disqualifies during early adult life (up to about 
thirty years of age) except as above. 

3. Multiplying cases of consumption in the family prejudice a risk in 
constantly increasing ratio. 

4. Family proclivity to any individual fatally-tending disease, or to 
insanity, suicide or abuse of alcoholic drinks or narcotic drugs, is prejudicial 
according to case. 



Appendix. 



IV. — Not Disqualifying, but Entailing Special Contract or 
Special Rate of Premium. 



Reducible hernia — special contract that death 
from neglect to wear a controlling truss is 
not insured against. 

Lack of successful vaccination — special contract 
that death from small-pox is not insured 
against. 

Total blindness — one-half per cent extra pre- 
mium chargeable. 

Total deafness — one-half per cent extra premium 
chargeable. 

Loss of lower extremity above the knee — one- 
quarter per cent extra premium chargeable. 

Female sex — one-half per cent extra premium 
chargeable until after attainment of age forty- 
eight. 

Negro blood, pure or mixed — one-half per cent 
extra premium chargeable to residents outside 
of the tropics. 



Occupation of locomotive engineer, railroad 
conductor, train-hand, switchman or coupler 
of cars — one-fourth to two per cent extra pre- 
mium chargeable. 

Extra hazardous occupation, generally ; as, for 
instance, mining or sea-faring — one-half to 
one per cent extra premium chargeable. 

Occupation of proprietor of inn or small hotel, 
or of merchant in, or manufacturer of, alco- 
holic drinks of any kind, where the business 
is strictly wholesale — extra premium of one- 
half per cent chargeable. (N. B. — Any occu- 
pation involving personal attention to the 
retailing of alcoholic drinks disqualifies abso- 
lutely. Such disqualification, therefore, at- 
taches to such distillers, brewers, or wine or 
liquor merchants as sell at retail, to saloon- 
keepers and to bar-tenders.) 



IO 



Appendix. 



IV.— LIFE INSURANCE STATISTICS. 

MALE LIFE DISEASES AND NUMBER OF DEATHS BY STATES AND TERRI- 
TORIES, ETC., IN TWENTY-SEVEN LIFE INSURANCE COMPANIES 
DURING A PERIOD OF THIRTY YEARS.* 



States and Terri- 
tories. 



X 




0. 




*» 




■- 








- 


o 
6 


"= 




P. 




- 


O 



Alabama 

Arkansas 

California 

Colorado 

Connecticut 

Delaware 

District of Columbia. 

Florida 

Georgia 

Idaho 

Illinois 

Indiana 

Iowa 

Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigan 

Minnesota 

Mississippi 

Missouri 

Montana, Nebraska 

and Nevada 

New Hampshire 

New Jersey 

New MexLo 

New York 

North Carolina 

Ohio 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

Tennessee 

Texas 

Utah 

Vermont 

Virginia 

Washington 

W T est Virginia 

Wisconsin 

Unknown 

British America 

Other foreign, 



IO 


5° 


.. 


21 


38 


78 


I 


1 


179 


165 


4 


11 


1 


23 


1 


10 


8 


45 


1 




I5« 


270 



63 135 

33 65 

11 21 

19 73 

9 112 

74 114 



26 

6 

121 

3 

3M 

10 

5° 

IO 

20 



398 106 

181 37 
97 28 
19 
93 
54 



Totals 



54 


104 


:-- 




69 


105 


43 


20 


7 


54 


75 


277 



- 
24 

12 

176 57 
857 229 



158 



9 

58 

54 

449 
7 

140 
2 

199 
15 
3 
8 



25 
15 

5 
121 



-5 
60 

97 

643 

39 

232 

4 

38 

160 
51 

33 
33 

1 

6 

142 
5 

37 
33 



162 
TO 
26 

178 



11 
no 
249 

1. 43i 

25 

408 



9, 



23 
8 

84 

1 

148 

3 

21 

4 
20 
1 
233 io 5 



67 

1 

131 

2 

9 
6 



575 
80 

14 
63 
20 

58 
34 

1 

13 

227 

2 

73 

4i 



5 » 

22 33 

44 49 

I 

- 

91 in 

, 3 3 

167 135 



92 

14 
49 

44 

79 
"3 

379 244 

7" 5: 

2Q 20 

14 9 

14 2 

65 23 

" 74 

3 

768 474 

14 8 

203 91 

1 1 

291 195 



>> 

6 

-. 


i 






>» 


- 


CO 










^ 


> 


M 


JJ 






J= 


M 






z 


- 



20 

II 

63 

2 
I08 

7 

19 

3 
16 



ID 
2 



3* 

3fi 

3 
26 

'3 

34 
66 



71 122 

2 n 
15 17 

3 2 
14 25 



42 

10 

22 

18 

3 

24 

17 

1 

10 

106 

45 
21 



235 
126 
46 
13 
53 
15 
48 
82 
245 
9i 
30 
20 

IOI 



143 

68 



2-1 
98 
38 62 






14 

5° 64 

57 91 

207 27^ 

55 95 

25 3° 

10 24 

71 120 



10 6 

40 40 

1 

57= m 

17 II 

i65 i6j 

3 3 

174 157 

30 11 



Q 

27 
20 

I 
23 
14 

2 

7 
114 

4 
36 
16 



661 
29 

3 
325 
35 
17 
46 
34 

2 

29 

17 



15 

145 

1 

39 



n 

92 

6 

i°3 

" 
14 
4 
206 

83 



46 

11 

11 39 
4 22 

8 57 



10 
12 
22 
136 
13 
9 
2 
16 



3i 
73 
49 
359 
88 
40 
19 
99 



1 16 
13 4i 



290 

3 

38 



206 

82 
805 

24 
1.648 

60 
203 

48 

I9 o 

2338 

996 

i,i 
557 
398 

816 

979 

4 108 

W § 
356 

220 

1.302 

108 

600 

1.029 

6 

7.443 

181 

2.186 

3* 

2.949 

377 

101 

441 

225 

9 

281 

205 

6 

84 

1,362 

45 

264 
2,3074,0496,4721,7051,7033,4031,9872,7112,0563,345 887 2.678 474 1,66535.442 



422 
9 

185 
5 

174 
16 



»5 

:: 

3 

4 27 
1 21 
1 

1 21 
3 



o 
*39 

4 
46 
33 



22 

4 
21 

14 

33 

43 

225 

57 

8 

12 
62 

4 
34 
56 

1 
46 

6 
35 

170 
18 

3 
14 
10 

12 
7 



* A treatise on the records of thirty American life offices. By Levi \V. Meech, in charge rf a committee of actuaries. 



Appendix. 



i i 



PROPORTIONAL DEATHS AND DISEASES TO 10,000 MALES LIVING IN EACH 

GROUP OF STATES. 



Group of States 

All causes 

Summary : 

Zymotic 

Constitutional 

Nervous 

Circulatory 

Respiratory 

Digestive 

Miscellaneous 

Zymotic: 

Typhoid, typhus 

Malarial fever 

Erysipelas 

Dysentery 

Diarrhoea 

Cholera 

Al -oholism 

Other zymotic 

Constitutional : 

Dropsy 

Cancer 

Consumption 

Other constitutional... 

Nervous: 
Apoplexy 

Congestion of brain.. 
Paralysis, softening brain 

Epilepsy, convulsions 

Other nervous 

Circulatory : 

Diseases of heart 

Other circulatory 

Respiratory : 

Pneumonia 

Congestion lungs 

Bronchitis, pleurisy 

Abscess, hemorrhage 

lungs 

Other respiratory 

Digestive: 

Diseases of stomach 

Diseases of bowels 

Peritonitis 

Diseases of liver 

Other digestive 

Miscellaneous: 

Diabetes 

Diseases of kidney 

Other urinary 

Childbirth, puerperal dis- 
eases 

Diseases breast and uterus 

Abscesses, hemorrhage, 
and old age 

Debility, exhaustion, etc. 

Accidents, injuries 

Suicides... 

Unknown causes 



105. 3 



17.6 
26.4 

154 
6.6 

13-3 

8.6 

17.4 



7.6 

1-7 

1.0 

1-7 
•9 
•9 
•3 

3-6 



1.8 

2.1 

20.8 

17 



5-2 
i-5 
7.2 

•3 
1.2 



6.1 

•5 



7-3 
1.8 
1 8 

1.9 
•4 



1.6 

1.9 

•7 
2.7 

1-7 



•5 

3-5 

•9 



1.2 
1 o 
7.2 

i-3 
1.8 



15.273 



III. 



97.7 107. 1 



18.5 
21.4 

"•5 
4.4 
14.6 

100 
17-3 



8-5 
23 
1-3 
1.4 

•7 
.8 

•3 
32 



1.6 

i-5 

16 9 

1.4 



3-8 

15 

5-2 

•3 

•7 



4.1 
•3 



8.5 
i-7 
2.0 

2.0 

•4 



2.2 
2.2 



2.4 
2-3 



•5 

1.4 

.8 



1.0 

9-7 

2 1 
1.0 

2,716 



16.6 

27.9 

15-4 

7-3 

12. 1 

11. 2 
16.6 



6.8 
1.8 
1.0 

•9 
1.0 
1.1 

•3 

3-7 

26 

2.1 

22.2 

1.0 



5-o 
2.1 

6-5 

.6 

1.2 



7-i 

.2 



6.6 
1.2 
i-5 



2.0 

2-5 

1.0 

3-7 
2 o 



•5 
3-i 
1.1 



1.1 

24 
6.0 

i-3 
1.1 

3.976 



IV. 



104.5 



18.7 
23.0 
14.4 
4.6 
16.6 
11. 2 
16 o 



19 
1.6 

18.5 
1.0 



4.2 

25 
6.2 

•4 
1.1 



4.4 
.2 



9.8 

17 
2.0 

2.4 
•7 



1.9 

2-5 



37 
23 



6,239 



I30-5 



27-5 
27-3 
20.1 
6. 7 
18.1 
11.9 
18.9 



69 
3-8 
1 3 
3-6 
1.6 
3-5 
•5 
6.3 



2.2 
2.2 

21.5 
1.4 



7.2 
2.9 
7.8 
•5 
1-7 



6-3 

•4 



10 8 

22.2 

1.8 

2.4 
•9 



2.1 
2-5 

•7 
3-9 
2.7 



•4 




•9 


2. 


•5 


. 


-- 




.1 


1. 


•7 


1. 


.0 


9 


3 


1. 


.1 


1. 



3.306 



VI. 



VII. 



C70.5 



48.4 

263 
22.3 

68 
21.5 
22 o 
23.2 



2 2 

1.1 

21.0 

2.0 



8.2 
4.9 
7-5 
•7 
1.0 



6.6 
.2 

12.6 

22.2 

3-4 

1-9 
1.4 



5-i 
5-8 
•5 
4.8 
5-8 



•3 
24 
1 2 



1.0 

1.1 

13-3 
1.4 

2-5 
2,153 



15-9 
22.1 
18.4 
9.2 
14.6 

9i 
22.9 



5-2 
1.9 
2 2 

i-5 
.2 

•9 
.6 

3-4 



1.9 
1.9 

16 9 
1.4 



6.8 
1-7 
7-3 
i-5 
1.1 



7-4 
1.8 



9.0 

•9 
2.2 



i-3 
1 6 

•3 
4.2 

1-7 



.6 

2.6 

•7 



•3 

1 2 

12.8 

33 

1-3 

863 



.5 2 



233 
24.9 
16.8 
6-5 
15-8 
12 o 
18.9 



0.6 
3-8 
1.4 
23 
i-3 
i-7 
•4 
59 



2.0 

1.8 

19.7 

1.4 



5-8 
2.4 
6.8 
.6 
1.1 



6.0 

•5 



9.2 

i-7 
2.1 



2-3 
2.7 
•7 
3-6 
2.6 



•5 
2.4 

•9 



1.0 
1.2 

9.6 
1.8 

i-5 



Groups. 



New England. 
New York. 



II. 

Northwest. 
Michiean. 
Wisconsin. 
Minnesota. 
Nebraska. 



III. 

New Jersey. 
Pennsylvania. 



IV. 

Ohio. 

Indiana. 

Illinois. 

Iowa. 

Kansas. 



Delaware. 

Maryland. 

Dist. Columbia 

Virginia. 

Kentucky. 

Missouri. 



VI. 

South 0/36° 30'. 

North Carolina 

South Carolina 

Tennessee. 

Georgia. 

Florida. 

Alabama. 

Mississippi. 

Arkansas. 

Louisiana. 

Texas. 



VII. 

Washington. 

Oregon. 

California. 

Utah. 

Dakota. 

New Mexico. 



12 



Appendix. 



A SANITARY SURVEY OF THE UNITED STATES. 

The respective annexed figures are arranged in ascending order, to show the proportional 
deaths by each disease among 10,000 insured males living in each group of States. 

The columns with single figures refer to the seven groups of States in the margin. 



Diseases. 



All causes. 



Summary 

Zymotic 

Constitutional 

Circulatory 

Nervous 

Respiratory 

Digestive 

Miscellaneous 



Zymotic : 

Typhoid and typhus. . . 

Malarial fever 

Erysipelas 

Dysentery 

Diarrhoea 

Cholera 

Alcoholism 

Other zymotic 



Constitutional : 

Dropsy 

Cancer 

Consumption 

Other constitutional.. 

Nervous: 

Apoplexy 

Congestion of brain. . 
Paralysis, softening of 

brain 

Epilepsy, convulsions.. 
Other nervous 



Circulatory : 
Diseases of heart. 
Other circulatory. 



Respiratory: 

Pneumonia 

Congestion of lungs. .- 

Bronchitis, pleurisy 

Abscess hemorrhage ot 

lungs 

Other respiratory. . . 



Digestive : 
Diseases of stomach. 
Diseases of bowels. . . 

Peritonitis 

Diseases of liver 

Other digestive 



Miscellaneous: 

Diabetes 

Diseases of kidney. . 

Other urinary 

Abscess, hemorrhage, 

old age 

Debility, exhaustiot 

and prostration . . . 

Accidents 

Suicides 

Unknown causes... 



Least Mortality. 



2977 



7 15-9 
2 21 4 
211.5 

2 4.4 

3 12. 1 
1 8.6 

4 16.0 



2 1.6 
6 1.1 
716.9 
3 



1.0 



2 3- 
1 1-5 



2 5.2 

1 -3 

2 -7 



2 4.1 
6 .2 



7 1.3 
7 -9 

7; i-5 

2 1 

7 



4 104-5 



16.6 
22 1 
144 

4.6 
13-3 

91 
16.6 



1 1.8 

2 i-5 

2 16.9 

3 1.0 



42 

IS 

62 

•3 
1.0 



44 
.2 



I I05-3 



17.6 
23.0 
15-4 
66 
146 
10.0 
17-3 



4 19 

4 1.6 

4 18.5 

2 1.4 



3 5-o 

7 1 7 

3 6.5 

4 -4 
7 11 



2 8.5 
2 17 
1 1.8 



4 1-9 

2 1.7 
1 1.8 

3 i-9 
3 



3 -5 

5 2 -l 
2 .8 



i.c 

9.0 

i-3 
1 1 



3107. 





18.5 
26.3 
15-4 
6.7 
14.6 
11. 2 
17 4 



7 19 

7 1.9 

1 20.8 

5 1-4 



S a 



1 7.2 
5 5 
4 11 



Greatest 
Mortality. 



7 112. 2 



4 18-7 

I 26.4 

7 184 

6 68 

4 16.6 

4 11. 2 

* 18.9 



6 2.2 

1 2.1 

6 21.0 

7 1-4 



6.6 
•4 



5 2.1 

4 1.8 
2 2.0 

5 2.0 

4 



II 

7 

5 -9 



5 130-5 



27-5 
27 3 
20.1 

7-3 
18.1 
11.9 
22 9 



7-6 

3S 
15 
3.6 
1.6 

2.4 

■5 

6-3 



5 2.2 

3 2.1 

5 21.5 

1 i-7 



7-2 
29 



6 7-5 
6 .7 
1 12 



7-i 
•5 



5 10 
5 2.2 
7 2.2 



2.4 

•9 



2 2.3 

5 2.2 

4 2.2 
7 2.4 

5 -9 



1.2 

1-3 

128 

2.1 

1.8 



6 1705 



484 

249 

22.3 

92 

21-5 

22.0 
23 2 



8-5 
11 8 
2.2 
5-8 
36 
3-5 
.6 
18.2 



2.6 

2 2 

22.2 

2.0 



82 

49 

7.8 
i-5 

17 



7-4 
1.8 



6 12.6 
6 2.2 
6 3-4 



2-4 

1.4 



6 5-1 

6 1 2.2 

3 3-4 

6 2.4 

6 1.4 



3-5 
1.2 

13 

24 

13-3 

3-3 

25 



118.3 



23-3 
24.9 
16.8 
6-5 
158 
12.0 
18.9 



66 

3-8 

1.4 

2-3 
i-3 
1-7 
4 
5-9 



2.0 

1.8 

19.7 

1.4 

58 
24 

6.8 

.6 

1.1 



6.0 

•5 



9.2 
1-7 

i-7 

2.1 

.8 



2-3 
2.7 
2.1 



•5 

2.4 

•9 



1.2 
96 
1 8 
i-5 



Group. 



New England. 
New York. 



Northwest. 
Michigan. 
Wisconsin. 
Minnesota. 
Nebraska. 



New Jersey. 

Pennsylvania. 



Ohio. 
Indi na. 
Illinois. 
Iowa. 
Kansas. 



Delaware. 

Maryland. 

Dist. Columbia 

Virginia. 

Kentucky. 

Missouri. 



South 0/36° 30' . 

North Carolina 

South Carolina 

Tennessee. 

Georgia. 

Florida. 

Alabama. 

Arkansas. 

Louisiana. 

Texas. 



7- 

Pacific, etc. 
Washington. 
Oregon. 
California. 
Dakota. 
Utah. 



Appendix. 



i3 



A GENERAL TABLE OF DISEASES AND DEATHS IN TWENTY-SEVEN LIFE 
INSURANCE COMPANIES DURING A PERIOD OF THIRTY YEARS. 



Number of Deaths. 



DISEASE- 



Males. 



Females. 



Total. 



Per Cent 
of Toia . 



A.l causes 



35,442 



2.1S2 



37.624 



Summary. 
Zymotic 

Constitutional diseases . . 

Nervous diseases 

Circulatory diseases 

Respiratory diseases 

Digestive diseases 

Miscellaneous diseases. . . 



Zymotic Diseases : 

Typhoid fever 

Typhus fever 

Cerebro-spinal fever 

Yellow fever 

Remittent fever 

Intermittent fever 

Congestive fever 

Typho-malarial fever 

Fever 

Smallpox 

Measles 

Scarlet fever 

Diphtheria and malignant sore throat, 

Erysipelas 

Pyaemia 

Carbuncle 

Influenza. ... 

Dysentery 

Diarrhoe 1 

Cholera 

Cholera morbus 

Goitre 

Malignant pustule 

Glanders 

Purpura hemorrhagica 

Alcoholism ■ 

Other zymotic diseases 



Constitutional Diseases : 

Anaemia 

Cancer 

Dropsy 

Gout 

Rheumatism 

Gangrene 

Tubercular meningitis 

Lumbar abscess 

Scrofula 

Tabes mesenterica 

Morbus coxae 

Consumption 

Other constitutional diseases. 



6-356 
8,175 
5,106 
1,986 
4.771 
3-344 
5.704 



2,147 

159 

23 

252 

412 

159 
213 

46 

255 
298 

13 

33 

127 

374 
70 
62 
12 

587 
328 

431 
195 

4 
11 

1 

21 

117 

1 



59 
621 
622 

63 
169 

51 

10 
11 

25 
88 
12 

6,474 
10 



303 
548 
193 
100 
291 

273 
468 



107 
11 

1 

6 
25 

7 
13 

4 
12 

7 
2 
2 
6 
10 

4 

1 
2 

35 
22 

15 

8 
o 
o 

o 
o 

I 

2 



12 
44 

56 

o 

II 

o 

I 
o 
6 

5 
o 

412 

I 



6,659 
8,723 
5.299 

2.092 
5,062 

3.617 

6,172 



2,254 
170 

24 

258 

437 
166 
226 

50 

267 

305 

15 

40 

133 

384 

74 

63 

14 

622 

350 

446 

203 

4 

II 

I 

21 

Il8 

3 



7i 

665 
678 

23 
180 

5i 
n 

31 
93 
12 

6,886 



17 70 
23.19 
14.08 

5.56 
13.45 

9.61 
16.42 



5-99 
•45 

.06 

.69 
1. 16 

• 44 
.60 

•13 
•71 
.81 
.04 
.11 

•35 

1.02 

.20 

• 17 
.04 

1.65 

•93 

1.19 

■ 54 
.01 

.03 
.00 
.06 

.31 
.00 



.19 

1.77 

1.80 

.06 

•48 

.14 

.03 

.03 

.08 

.25 

•03 

18.31 

.03 



M 



Appendix. 



General Table of Diseases and Deaths — Continued. 



DISEASES. 



Circulatory Diseases : 

Disease of the heart 

Pericarditis and endocarditis . . 

Hypertrophy of the heart 

Valvular disease of the heart . . 
Fatty degeneration of the heart 

Dropsy of the heart 

Atrophy of the heart 

Paralysis of the heart 

Rheumatism of the heart 

Abscess of the heart 

Angina pectoris 

Aneurism of aorta 

Rupture of aorta 

Embolus of pulmonary artery. . 

Phlebitis 

Other circulatory diseases 



Respiratory Diseases : 

Epistaxis 

Disease of larynx 

Bronchitis 

Pleurisy 

Congestion of lungs . . 

Pneumonia 

Abscess of luDgs 

Hemorrhage of lungs. 

Disease of lungs 

Emphysema, asthma . 
Pulmonary apoplexy . 
Gangrene of lungs. . . . 



Number of Deaths. 



Males. Females. 



Ail causes 35.442 



Nervous Diseases : 

Apoplexy 

Congestion of the brain 

Softening of the brain 

Paralysis 

Disease of the brain 

Convulsions and epilepsy 

Insanity 

Anxiety 

Fright 

Encephalitis 

Cerebro-spinal sclerosis 

Cerebral embolism 

Anaemia of the brain 

Effusion on the brain 

Neuralgia 

Progressive muscular atrophy. . 

Tetanus 

Inflammation of the spinal cord 

Disease of the spinal cord 

Congestion of the spinal cord. . 
Other nervous diseases 



2,182 




1,705 


61 


1,766 


4 70 


655 


14 


669 


1.78 


399 


9 


40S 


1.09 


S41 


32 


S73 


2.32 


721 


37 


--'- 


2.02 


130 


8 


13S 


•37 


140 


6 


146 


39 


2 





2 


.01 


1 





1 


.00 


277 


10 


2^7 


.76 


1 





1 


.00 


1 





1 


.00 


8 





a 


.02 


48 


3 


51 


.14 


17 


1 


iS 


.05 


3 





3 


.01 


47 


4 


= 1 


.14 


18 





18 


.05 


41 


2 


43 


.11 


3 





3 


.01 


4S 


6 


54 


• 14 


1,297 


62 


1.359 


3.61 


104 


9 


113 


•30 


100 


4 


104 


.28 


gS 


6 


104 


.28 


42 


3 


45 


.12 


56 


6 


62 


.16 


4 





4 


.01 


27 


1 


2S 


.07 


66 


6 


72 


.19 


5 





5 


.01 


79 


4 


83 


.22 


^1 


1 


52 


• 14 


16 


1 


17 


.05 


5 


1 


6 


.02 


l8 





iS 


.05 


18 


2 


20 


.05 


8 







.02 


112 


3 


115 


• 31 


437 


21 


45S 


1. 21 


172 


7 


179 


.45 


56S 


20 


597 


I.5Q 


2.713 


176 


2.SS9 


7.63 


7S 


6 


S4 


.22 


2S3 


7 


290 


• 77 


264 


3i 


295 


.73 


63 


8 


71 


.19 


34 


1 


35 


.09 


13 





13 


• 03 



Appendix. 



General Table of Diseases and Deaths — Continued. 



DISEASES. 



All causes 

CEdema of lungs 

Otber respiratory diseases 

Digestive Diseases . 

Inflammation of the stomach 

Ulceration of stomach 

Disease of stomach 

Hemorrhage of stomach 

Congestion of stomach 

Tumor of stomach 

Inflammation of bowels 

Ulceration of bowels 

Hemorrhage of bowels 

Congestion of bowels 

Disease of bowels 

Obstruction of bowels 

Perforation of bowel s 

Peritonitis 

Gastro-enteritis 

Disease of stomach and bowels 

Strangulated hernia 

Colic, tympanites and constipation 

Dyspepsia 

Gangrene of tongue 

Stricture of oesophagus 

Fistula in ano 

Disease of spleen 

Leucocythaemia 

Ascites 

Abdominal tumor 

Hemorrhage 

Undefined diseases of abdominal organs 

Jaundice 

inflammation of liver 

Cirrhosis of liver 

Abscess of liver 

Diseases of liver 

Congestion of liver 

Hypertrophy of liver 

Acute yellow atrophy of liver 

Fatty degeneration of liver 

Biliary calculus 

Oostruction of hepatic duct 

Rupture of gall bladder 

Otder digestive diseases 

Miscellaneous Diseases : 

Bright's disease 

Inflammation of kidneys 

Abscess of kidneys 

Tumor of kidneys 

Disease of kidneys 

Diabetes 

Addison's disease 



Number of Deaths. 



Males. 



Females. 



>5.442 



319 

75 

150 

57 

23 

4 

425 

67 

S4 

22 

IOO 
36 

6 
246 

165 

127 

43 
69 

43 
3 

11 

12 

22 

7 

4i 

35 

9 

75 

11 

26S 

104 

79 

448 

63 

36 

9 

15 

15 

4 

2 

14 



r:' 



;o 

60 

12 

1 

255 

15s 

12 



2,182 



39 

6 

5 
1 
2 
o 

45 

6 
2 

5 
10 

1 

41 

17 

7 



Total. 



Per Cent 
of Total. 



37.024 



353 
Si 

155 

58 

25 

4 

470 

73 
86 

27 

no 

37 

7 

2S7 

182 

134 

55 

72 

46 

3 

n 

12 

22 

8 

49 

3S 

9 
n 

77 
283 
108 

86 
467 

66 

3S 
9 

16 

15 
4 
2 

16 



567 

61 

12 

1 

264 

161 

12 



.04 
•03 



•95 
.22 

•4i 
•15 
.07 
.01 
1-25 
.19 
.23 
.07 

.29 
.10 
.02 
.76 
. 4 3 
06 

• 15 
.19 
.12 
.01 

• 03 
•03 
.06 
.02 

•13 
.10 
.02 
.03 
.20 

•75 
.29 

•23 
1 24 

.18 
.10 
.02 
.04 
.04 
.01 
.01 
.04 



1. 51 

.16 

•03 

.70 

■43 
.04 



i6 



Appendix. 



General Table of Diseases and Deaths — Continued. 



DISEASES. 


Number of Deaths. 

PerCenr 


1 
Males. Females. 


' of Total. 
Total. 


All causes 


35 442 2,182 


37,624 100 00 



Miscellaneous Diseases — Cont. 

Inflammation of bladder 

Disease of bladder 

Hemorrhage of bladder 

Rupture ot bladder 

Urinary calculi 

Gravel 

Disease of prostate gland 

Stricture of urethra 

Gangrene of scrotum 

Other urinary diseases 

Childbirth and puerperal diseases 

Diseases of breast and uterus 

Debility, exhaustion and prostration.. 

Abscess 

Hemorrhage 

Tumors 

Inflammation of joints 

Old age 

Accidents and injunes 

Suicides 

Unknown causes 



74 

54 

5 

1 

2 

33 

39 

5 

1 

66 



377 
117 
66 
55 
15 
S7 
2,678 

475 
508 



2 
1 
o 
o 
1 
o 
o 
o 
o 
5 
197 
no 

28 

5 

9 

3 

o 

12 

34 

7 

24 



76 


.20 


5 5 


•15 


5 


.01 


1 




21 


.06 


T 3 


.03 


39 


.10 


5 

1 


.01 


71 


.19 


197 


■ 52 


no 


.29 


405 


1.08 


122 


.32 


75 


.20 


53 


.15 


15 


.04 


99 


.26 


712 


7-21 


482 


1.23 


532 


1.42 



INDEX. 



Page. 

Abdomen— Examination of the 73 to 76 

Ascites 115, 167 

Diseases of the 10, 17, 73 to 76, 150 to 168 

Retraction of the 74 

Tumors of the 75 

Acceptances — General Rules 107 

Rules of Parts II. and III. 

Rules of — See Various ' ' Heads ' ' and ' ' Dis- 
eases." 

In Constitutional Diseases 107 to 118 

In " Hereditary Diseases" 97 to 106 

Accidents vs. Occupation 24 

Activity ot Temperament 38 

Acute, Bronchial and Lung Diseases 127 

Addison's Disease of the Supra-Renal Cap- 
sules 118, 181 

The Countenance in 40 

Adhesions — Pleuritic 135 

Ages — Diseases Peculiar to 29, 30 

Apparent 30 

See " Heredity." 

Inherited Taint Appears See "Heredity." 

Relative of Parents 98 

Premature Old Age 31 

And the Pulse 70, 71 

And Respiration 53 

Agents— Instructions to Appendix 6 

Legal Status of Appendix 4 

R°port Appendix 6 

Albumin — Tests for 17, 79 to 81 

In Urine, Diseases Causing 79 to 81 

Albuminuria — The Countenance in 40 

Diseases Causing 79 

Albuminuria 174 

Alcoholism — The Countenance in 40 

Heredky and Transmission of 105 

Acceptance, Postponement, Rejection. 105, 113 

Or Intemperance 185 

Alimentary Diseases io, 17, 150 to 168 

American Life Expectation Table 32 

Army Mortality 40 

Amputations , 183 

Amyloid Kidney 177 

Anasmia — The Countenance in 40 

Cachexia 40, 116 

Varieties and Symptoms 116 

Anasarca 116 

Ancestors, Longevity of 99 

Aneurism — Thoracic 149 

Angina Pectoris 148 

Aortic Obstruction 137, 138 



Page. 

Aortic Regurgitation 138 

Aphonia 127 

Apoplexy, Heredity and Transmission of. . . . 105, 

ic6, 114 

Appearance, General 35 

Appendix 189 

Applicants — Examination of, Part II 22 to 98 

Legal Status of. Appendix 4 

For Large Insurance 17 

Applications, Female 20 

Application, Use the Latest Form of 12 

Arcus Senilis 40 

Army — British Mortality 44 

U. S. Mortality 43 

Army and Navy Risks 24 

Arteries, Diseases of. 149, 150 

Artisans as Risks 23 

Artists as Risks 23 

Ascites 115, 167 

Asthma 131 

Atavism, Laws of — see " Heredity " 99, 103 

Atheroma of Arteries 149 

Atrophy of the Brain 123 

Of the Heart 147 

Amphoric Resonance 57 

Auscultation of the Lungs 58,59, 60 

Of the Abdomen 76 

Of the Heart , 64 to 68 

Of the Voice 60, 61 

IB 

Balance of Temperaments 39 

Basedow's Disease 148 

Bibliography 188 

Bile— Heller's Test for 84 

Pettenkofier's Test for 84 

Biliary Disorders of the Liver 163 

Bismuth, or Boettger's Test 83 

Bladder Diseases 181 

Blindness 45 

Blood and Blood-making Organs, Diseases of 

107 to 118 

Blood in Urine — Tests for 84, 85, 96 

Blood-vessels— Diseases of the 10, 16, 136 

And Heart, Diseases of 136 to — 

Boettger's, or Bismuth Test 83 

Brain — Countenance in Softening of 40 

Diseases of the 122 to 126 

Breathing — Varieties in Disease 59, 60 

See Respiration 51 , 54 

Or Tidal Air 51 

Bright's Diseases of the Kidneys 175 

Bronchi and Lungs, Diseases of 127 to 136 



Index. 



Page. 

Bronchitis, Chronic 130 

Bronchial Breathing 59 

Broncho- Vesicular Breathing 59 

Buboes 182 

C 

Cachexise — Th*» 45 

Addison's Disease 40 

Anaemic 40, 45, 116 

Alcoholic 40, 113 

Cancerous 40, in 

Chlorotic 45 

Consumptive 39, 45, 107 to 111 

Erysipelatous 45 

Gouty in 

Insane 113 

Malarial 40 

Rachitic 45 

Renal 40 

Rheumatic 112 

Scrofulous or Strumous 45, ioi, in 

Syphilitic 40, 45, 112 

Tuberculous 44 

Tuberculous, Countenance 39 

Calculi , Renal 180 

Cancer — Heredity and Transmission of 101 

Age of Development of 101 

Causes for Acceptance 101 , in 

Causes for Rejection ioi, in 

Of the Kidneys 179 

Of the Liver 165 

Of the Lungs 134 

Of the Stomach 156 

Cardiac See Heart. 

Carlisle Mortality Table 31 

Casts — In Urine 91 to 94 

Exudative or Fibrinous 93 

Desquamative or Epithelial 93 

Fatty 93 

Granular 93 

Hyaline or Waxy 93, 94 

Catarrh 126 

Census — U. S. Mortality Report 42 

Cells, Epithelial, in Urine 94 

Cerebral See " Brain." 

Chancroid 112, 182 

Change of Life 186 

Chest — Examination of the 51 to 61 

Diseases Causing Contraction of 56 

Diseases Altering the Form of 56 

Tumors Within the 56, 57, 132 

Chest-girth and Consumption 54 

Height and Weight 16, 49, 50 

Chorea 121 

Chyle in Urine, Test=; for 85 

Circulation, Healthful 38 

Cirrhosis of the Kidneys 178 

Of the Liver 166 

City and Country Risks . . , 23 

Clergymen as Risks 23 



Page. 
Climate 27 

Colic— Intestinal 160 

Flatulent 161 

Hepatic 161 

Lead jgj 

Renal 180 

Collapse of the Lungs 135 

Color of Urine 77 

Companies, Legal Contracts of Appendix 4, 5 

Complementary Air 51 

Complexion, Effects of Diseases on 40 

Confidential Instructions 19 

Congestion of the Liver 163 

Of the Kidneys , 175 

Consanguinity of Parents 98 

Consciousness, Loss of, or Syncope 122 

Constipation, Habitual 160 

Constitutional Diseases 107 to 118 

Constitutional Taint See " Heredity." 

Consumption 108 to ill, 136 

Adverse Environment 99 

Cachexia 39 

Catarrhal 108 

Causes of. 109 

Causes for Acceptance 100, 101, no, 111 

Causes for Postponement 100, 101, no 

Causes for Rejection 100, 101, no 

And Chest-girth 54 

Among Children 100 

Fibrous 108 

Germ Theory 109 

And Hardships 99 

Heredity, and Transmission of 99 to 101 

Inherited , Develops 99 

Measure of Virulency 100 

Mortality in Army 44 

White vs. Black Troops 44 

Negro Mortality 44 

Predisposition to 99 to 101, 109 

And Robust Physiques 99 

Rules for Estimating Risks 100, 101 

Susceptibility to 99 to y>i, 109 

Symptoms of 109 

Transmission from Father ico 

Transmission from Mother 100 

Tubercular ic8 

Virulency of the Taint 99 

And Wasting Diseases in Parents 99 

Contractions of the Liver 164 

Convulsions 113, 121 

Cough 128 

Countenance in Addison's Disease 40 

Albuminuria 40 

Anaemia 40 

Brain Softening 40 

Cancerous Cachexia 40 

Heart Hypertrophy 40 

Insanity 40 

Intemperance 40 

Kidney Affections 40 



Index. 



in 



Page. 

Countenance in Liver Diseases 4° 

Malarial Affections 4° 

Paralysis 4° 

Tuberculous Cachexia 39 

Wasting Diseases 4° 

Cracked-pot Resonance 57 

Crystals in Urine 88 to 91 

Cystitis, Chronic 181 

3D 

Deafness 46 

Death, Proofs of 20 

Deaths from Consumption 44 

From Malarial Diseases 44 

From Other Diseases 41 , 42, 43, 44 

Whites vs. Negroes 4 2 > 43 

Of White and Black Troops 44 

Deformities 4 6 > l8 3 

Degenerations— Albuminoid 1 15 

Amyloid "5. i 6 5 

Atheromatous 11 5 

Calcification 1Z 5 

Cheesy "5 

Colloid "5 

Fatty US. 147. 165 

Hyaline ■ "5 

Lardaceous IX 5 

Pigmentation H5 

Tissue US 

Deposits in the Lungs x 33 

Growths, Tumors of Brain 123 

Derangements of Motion 120 

Of Sensation 122 

Development, Physical 44 

Diabetes and Light Hair 4° 

Urine and Symptoms 82 

Insipidus x 7° 

Mellitus 171 

Diarrhoea, Chronic 158 

Diathesis 9» 45 

Acquired 45 

Adipose 45 

Alcoholic 4° 

Cancerous, Countenance in 45 

Gouty 45 

Inherited 45. 97 to 106 

And Nutrition 9- 45 

And Nutrition, Diseases of 107 to 118 

Rheumatic 45 

Strumous or Scrofulous 45, 101 

Tuberculous, Countenance in 39 

Digestion, Healthful 38 

Dilatation of the Heart 145 

Of the CEsophagus 152 

Of the Stomach 155 

Diphtheria 127 

Diseases of the Abdomen 73 to 76 

Abdominal and Alimentary. .- 10, 17, 150 to 168 

Peculiar to Ages 29, 30 

Causing Albuminuria 79 



Page. 
Diseases, Blood and Blood-making Organs 107 to 118 

Of Blood-vessels and Heart 10, 136 to 149 

Of the Brain 122 to 125 

Varieties ot Breathing in 59, 60 

Causing Chest Expansion 56 

Causin g Chest Contraction 56 

Altering the Form of Chest 56 

Climate Causing 27 

And Complexion 40 

Constitutional 107 to 118 

And the Countenance 39, 4a 

Countenance in Wasting 40 

Time of Development of 30 

Diathetic and Nutritive 9, 107 to 118 

External Marks of 44 

Genito-urinary 10, 17, 168 to 182 

And Hair and Eyes 40 

Displacing the Heart 62, 63 

Affecting Cardiac Impulse 63 

Affecting Cardiac Rhythm 63, 64 

Affecting Cardiac Sounds 65, 66 

Hereditary 8, 98 to 106 

Susceptibility to, Inherited 97 to 106 

Relating to Life Insurance. Part II. . .98 to 102 

Of Lungs, Percussion Sounds 57 

Mortality from 42, 43, 44 

Nervous , 9, 119 to 126 

Physiological Conditions of 98, 99 

Predisposition to 14 

Predisposition to, Inherited 97 to 106 

Affecting the Pulse 69 to 73 

Affecting Respiration 56 

Respiratory 10, 127 to 136 

Of the Skin 9, 118 

Of the Organs of Special Sense 10, 118 

Of the Spinal Cord 125 

Of the Spleen 118 

Affecting Different Temperaments 39 

Transmission of. 98 to 106 

Transmission of Single See ' ' Heredity." 

Urinary 10, 17, 168 to 182 

Affecting the Urine yy to 97 

Affecting Specific Gravity of Urine 78, 79 

Causing Sugar in Urine 81 to 84 

Causing Casts in Urine 91 to 94 

Displacements of the Heart 148 

Dispncea 129 

Dullness — Pulmonary 57 

Dropsy 115, 116 

Drunkards ; See "Alcoholism." 

Duties — Examiner's Confidential 19 

Dysentery— Chronic 159 

Dyspepsia 17, 153 

Emphysema 131, 135 

Encephalitis 122 

Endarteritis Defoimans 149 

Endocarditis 136, 137 

Enlargement of the Liver 164 



IV 



Index. 



Page. 

Enlargement of the Kidneys 163 

Environment 7. 22 

Consumption in Adverse 99 

Epilepsy— Heredity and Transmision of. . .104, 105 

Acceptance, Postponement, Rejection 104, 

105, 113 

Ep thelial Cells in Urine 94 to 96 

Examination of the Applicant. Part II 22 to 98 

Urine for Life Insurance. Dr. \V. J. 

Lewis 80 

Examiners — Duties of the Medical 5, 6 

Medical Report of 7 

Instructions for 12 to 29 

Legal Status of Appendix and 5 

Excitability of Temperament 38 

Executive Officers — Duties of 107 

Exercise and Chest Expansion 54 

Expansion of the Chest 54-55 

Expectation of Life Tables 31, 32, 33, 34 

Expiration 51, 53, 54 

Expiratory Power 53 

Eyes and Hair 4° 

Family Record 8, 14 

See " Heredity Influences " 98 to 106 

Fauces — Diseases of the 150 

Fees of Examiners 21 

Fehling's Test Solution 18, 82 

Female Certificate 12 

Insurance 12, 20, 35, 185 

Figure — Physical Proportions 41 

Fistula in Ano 41 

Fits— Spasms or Convulsions 121 

Formalities, Life Insurance 7 to 21 

Appendix. 

Or 

Gastritis— Chronic 154 

Gastrodynia 153 

Generation, Diseases of Organs of io, 17, 181 

Genito-urinary Organs, Diseases of 10, 17, 168 

Germ Theory of Consumption 109 

Glycogenic Disorders of Liver 162 

Gonorrhoea 182 

Gout — Heredity and Transmission of. 101 

Acceptance, Postponement, Rejection 101 

in, 112 

Growths— Deposits, Tumors of Brain 123 

Morbid Nasal 127 

Renal 180 

Habits, Personal 11, 15, 184 

Habit — Opium 185 

Nervous Stimulants 185 

Hasmatuna 172 

Haemoptysis 135 

Haemorrhoids 150 

Hair and Eyes 40 

Hair — Falling in Syphilis 40 

Diabetes and Light 40 



Page. 

Half-breeds and Negroes 183 

Headache — Causes and Varieties 119 

Health— General Record n, 12, 15, 182 

Physiological Conditions of 38 

Heart — Examination of the 61 to 68 

Angina Pectoris 148 

Atrophy 147 

Basedow's Disease 148 

Affections, Complexion in 40 

Dilatation 145 

And Blood Vessels — Diseases of 136 t"> 150 

Displacements 62, 63 

Fatty Degneration 147 

Hypertrophy 144 

Hypertrophy, Countenance in 40 

Malformations and Displacements 148 

Murmurs 66 to 68, 142, 143 

Myocarditis -• 147 

Nervous Palpitation 148 

Thrombosis 146 

Valves — Location of 62 

Valvular Lesions of 137 to 142 

Hebrew Risks 35 

Height and Weight 47 to 50 

Weight and Chest-girth 16, 49, 50 

Extremes of. 48 

Of Different Races 48 

Respiratory Power 53 

And the Pulse 71 

H.matemesis 156 

Heredity — Transmission of Diseases 98 to 106 

Collateral Physiological Conditions 98, 99 

Laws of Atavism 99, 103 

Direct and Indirect 99 

Family Record 8, 14 

Intermarriage of Races 98, 99 

Longevity of Ancestors 99 

Stirpiculture 99 

Hernia 4 6 - 47 

Hodgkin's Disease or Lymphadenoma 117, 118 

Hydatids of the Liver 166 

Hvdronephrosis 169 

Hydro-pneumo-thorax 135 

Hydrothorax 135 

Hypertrophy of the Brain 123 

Of the Heart 144 

With Dilatation 14 6 

Of the Heart, Countenance 4° 

Hysteria I2 ° 

I 

Identification 7- 22 

Examiner Responsible for 13 

Illness, Previous Serious 182 

Inflammation, Spinal 125 

Inherited Diseases See " Heredity." 

Injury, Previous 183 

Insanity, The Countenance in 4° 

Expression of Eyes in 4° 

Heredity and Transmission of 102 to 104 



Index. 



Page. 

Insolation or Sunstroke 124 

Inspiration 51, S3, 54 

inspiratory Power 53 

Instructions to Agents Appendix 7 

To Medical Examiners 12 

Confidential 19 

Insurance— Solicited by Examiners 13 

Executive Officers 107 

Female 185 

Large Amount of 17 

Previous 183 

Statistics, Appendix 10 

Special Rates, Appendix 9 

Intemperance See Alcoholism. 

Intermarriage of Races 9 8 > 99 

Intestines, Diseases of the 157 

Irritation, Spinal I2 5 

J- 

Jaundice • l66 

Jews as Risks 35 

Kidney Affections— Countenance in 40 

Lower Eyelids in 4° 

Kidneys — Diseases of the 168 to 181 

Location, Percussion 7 6 

!_. 

Laryngitis, Chronic 127 

Larynx— Aphonia 127 

Diseases of the i 2 7 

Lawyers as Risks 23 

Leanness or Obesity, Extreme 115 

Lecturers as Risks 23 

Legal Status of Agents Appendix 4 

Of Applicants Appendix 4 

Of Companies Appendix 4, 5 

Of the Examiner Appendix 1, 5 

Leucocy thaemia 1 17 

Leukaemia 117 

Lewis, Dr. W. J., Examining Urine for Life 

Insurance 80 

Life, Expectation of 31, 32, 33, 34 

Life Insurance Formalities 7 to 21 

Formalities Appendix 6 

Latest Court Decisions Appendix 4 

Diseases Relating to 98 to 182 

Examination of Applicant 22 to 98 

And Examiners Appendix 2 

History of Appendix 1 

Liver — Location, Percussion 75 

Diseases of the 162 to 167 

Locomotor Ataxia or Tabes Dorsalis 125 

Longevity of Ancestors 99 

Loss of Consciousness 122 

Lungs — Diseases of Bronchi and 127 to 136 

Auscultation in Disease 58, 59, 60 

Cancer of the 134 

Collapse of the 135 

Deposits in the 133 



Page. 

Lungs — Percussion Sounds in Disease 57 

Percussion Sounds in Health 58 

Rales in Disease 60 

Syphilis of the 134 

Lymphadenoma or Hodgkin's Disease 117, 118 

:m: 

Malarial Cachexia 40 

Male or Female 34 

Malformations of the Heart 148 

Marriage — Married or Single 34 

See " Heredity." 

Of First Cousins 98 

Intermarriage of Races 98 

Married or Single 34 

Masturbation 182 

Mechanics as Risks 24 

Medical Adviser 11, 18 

Directors, Duties of 107 

Menopause 186 

Menstruation 187 

Metabolic Disorders of the Liver 163 

Microscopical Examination ol Urine 17, 88 to 97 

Millard, Dr. H. B., Urinary Tests 79 

Mitral Obstruction 139 

Regurgitation 139 

Mortality Among 5000 Risks 30 

From Accidents 42 

From Alcoholism 41 

From Apoplexy 41 

From Cancer 41 

From Consumption 41, 44 

From Digestive Diseases 42 

From Heart Disease 41 

From Kidney Diseases 41 

From Malarial Diseases 44 

Male vs. Female 34 

Of Different Nationalities 41 

Of Races - 41, 42, 43 

Of Whites vs. Negroes 42, 43, 44 

Of White vs. Black Troops 44 

Suicides 42 

Tables 30, 31, 32, 41 to 44 and Appendix 

Motion — Derangements of 120 

Defective Co-ordination 121 

Rigidity 121 

Paralysis 121 

Mouth, Diseases of the 150 

Mucus in Urine 85 

Multipara? 186 

Murmurs, Heart 66 to 68, 137 to 142 

Anaemic, Hcemic or Blood 143 

Diastolic Heart 68, 142 

Systolic Heart 68, 142 

Endocardial 68, 137 to 142 

Induced, Cardiac 143 

Inorganic, Functional 143 

Pericardial - .68, 143 

Venous 143 

Ventricular 143 



Index. 



Page. 

Muscles, Derangements of 120, 121 

Myocarditis 147 

1ST 

Name of Applicant 7, 22 

Nationalities, Mortality of. See " Race " 

Nativity See ' ' Race. 

N avy and Army Risks 24 

Negroes and Half-Breeds 183 

vs. Whites, Mortality 42, 43, 44 

Army Mortality 44 

Consumptive Mortality 44 

Mortality from Malarial Diseases 44 

Nephritis, Parenchymatous 176 

Nervous Diseases 9 

Heredity and Transmission 102 to 106 

Affec ions of (Esophagus 152 

Nervous Diseases and Respiration 53 

Neuralgia, Intercostal 132 

Neurasthenia 124 

Nitric Magnesian lest 80 

Nose, Morbid Growths in the 127 

Nutrition and Diathesis 9, 107 to 118 

Diseases of 107 to 118 

O 

Obesity and Chest Expansion 55 

Or Leanness, Extreme 115 

Obstruction- Aortic 137, 138 

Mitral 139 

Pulmonic 140 

Tricuspid 141 

Occupation 7, 22, 44 

Occupations Causing Rejection 19 

vs. Accidents 24 

Previous , 24 

Hazardous 24 

(Edema 115 

Of Lower Eyelids 40 

(Esophagus — Diseases of the 151 

Organic Stricture 151 

Nervous Affections 152 

Dilatation of the 152 

Opinion, Medical Examiner's 11, 19 

Opium Habit 185 

Oxalate of Lime in Urine 91 

IP 

Pain in the Thorax 128 

Palpation of the Chest 56 

Paralysis — the Countenance in 40 

Heredity and Transmission of 106 

SpinT 125 

Parenchymatous Nephritis 176 

Parents— Relative Ages of 98 

Consanguinity of 98 

Age when Taint Appears 98 

Physical Sameness of 98 

Intermarriage of Races 98, 99 

Longevity of Ancestors 99 

Direct and Indirect Heredity 99 



Page. 

Parents— Law of Atavism 99 

Pjrt I . Insurance Formalities 1 to 22 

Part II. Examination of the Applicant 22 to 98 

Part III. Diseases Relating to Life Insurance, 

98 to 182 

Percussion of the Chest 56, 57, 58 

Pericardial Murmurs 68, 143 

Pericarditis i_^ 

Peritoneum, Diseases of the 157 

Peritonitis, Chronic 157 

Pharynx, Diseases of the 150 

Phosphates in Urine 86, 87 

Physician, Family n, 18, 18; 

Physicians as Risks 2: 

Physique 8, 14, 29 

And Consumption 99 

Physiological Conditions of Health 38 

Conditions of Heredity 98.99 

Pleuritic Adhesions 135 

Friction Sounds 68 

Pleurisy— Chronic 134 

Plethora 117 

Pleurodynia 13;; 

Pneumonia — Chronic 13J. 

Poisoning — Chronic Cerebral 124 

Policyholders — Violation of Contract bv 13 

Legal Status Appendix 4 

Postponements— General Rules 19, 107 

Rules of Parts II. and III. 

Rules of. See various "Heads" and "Diseases." 

Postures — Affecting the Pulse 71 

Predisposition to Disease 14 

To Consumption 99 

Inherited or Acquired 99 

To Various Diseases 98 to 106 

Previous Occupation in Risks 24 

Pnmiparae 186 

Professional Men as Risks 22 

Proofs of Death 20 

Prostate — Enlarged 181 

Prostatitis 181 

Pulmonary Diseases See Lungs. 

Pulmonic Obstruction or Stenosis 140 

Regurgitation 140 

Pulse— The 16 

Examination of the 69 to 73 

Age Changing the 70 

Anomalies of 73 

Affected by Diseases 69 to 73, 150 

Force of the 72 

Frequency of th j 70, 150 

And Height 71 

Intermittent 71 

Irregular 71, 72 

Male and Female 71 

Normal Beats 71 

in Different Postures 71 

Rate — Postponement 73, 150 

Rhythm of the 71 

Low Tension 70 



Index. 



VI 1 



Page. 

Pulse— High Tension 70 

Tracings 69 

Typical Tracings 69, 70 

Modified Tracings 7° 

Varieties of Hard 73 

Varieties of Soft 73 

Other Varieties of 7 2 . 73 

Pupils of Eyes 4° 

Purpura 117 

Pus in Urine 85, 96 

Pyelitis 169 

Quality an Element of Health 38 

Quetelet's Table, Male vs. Female Deaths 34 

Quinsy or Tonsillitis 127 

Tl 

Race and Mortality Rates 41 

Mortality of Whites and Blacks 42, 44 

Races— Comparative Height of 48 

Intermarriage of 98. 99 

Rahs in Pulmonary Diseases 60 

Regurg tation— Aortic 138 

Mitral 139 

Pulmonic 140 

Tricuspid 140 

Rejections 19 

Causes for 19, 20 

General Rules 107 

Rules Parts II. and III. 

Rejections Appendix 7 

Occupations Causing 19 

Previous, Reported 13 

Previous 183 

Report — Medical Examiner's 7 

Agents Appendix 6 

Residence 7 

Resonance, Pulmonary 57 

Respiration 51, 53, 54, 55, 56 

And Age 57 

And Sex 56 

Affected by Diseases 36 

Healthful . . . 38 

Irregularities of 53 

And Nervous Disorders 53 

And Lung Disease 53 

And the Spirometer 54 

Respiratory Diseases 10, 16, 53, 126 to 136 

Power or Vital Capacity 53 

Table of 53 

Height and Weight 53 

Movement 55 

Rheumatism, Heredity and Transmission of... 102 
Risks — Rules for Acceptance of. See Parts II. 

and III. and 107 

Accidents in 24 

Army and Navy 24 

Artisans as .'. 23 

Artists as 23 



Page. 

Risks— The Best 27 

City vs. Country 23 

First Class 22, 23, 24 

Second Class 23 

Classification of 24 

Clergymen as 23 

Climate Affecting 27 

Estimating in Consumption 100, 101 

Rules for Estimating in Disease. Part III. 

97 to 182 

Engineers as , 24 

Female 35 

Final Judgment on 107 

Glaziers as 24 

Hazardous 23 

Hebrews 35 

Lawyers as 23 

Lecturers as 23 

Married 34 

Unmarried 35 

Mechanics as 23 

Miners as 24 

Navy and Army 24 

Occupation Affecting 22, 24 

Previous Occupation 24 

Painters as 24 

For Limited Periods 101 

Plumbers 24 

Physicians as 23 

Rules for Postponement of. See Parts II. 

and III. and 107 

Professional Men as 22 

Rules for Rejection. See Parts II. and 

III. and 107 

Sailors as 24 

Teachers as 22 

Roberts, Dr. Sir William's Test for Sugar. . .80, 83 
Rules, General, for Examiners 12 

S 

Sailors as Risks 24 

Scarlet Fever 184 

Scrofulous or Strumous Diathesis 45, 101, 111 

Sensation, Derangements of 122 

Sexes — Comparative Height of the 48 

Comparative Weight 48 

Respiration 53 

The Pulse 71 

Signature 7, 22 

Skin Diseases 9, 118 

Small-pox 184 

Softening of the Brain 40 

Soldiers as Risks 24 

Sounds, Heart 64 to 68, 137 

Spasms 121 

Special Sense, Diseases of Organs of. 10, 45,46, 118 

Specific Gravity of Urine 17, 78, 79 

Altered by Disease .78, 79 

Spermatorrhoea 182 

Sphygmograph, Pulse Register 69 



Vlll 



Index. 



Page. 

Spinal Cord, Diseases of the 125 

Spirometer and Respiration 54 

Spleen — Location of the 76 

Diseases of the n8, 167 

Statistics, Life Insurance Appendix 10 

Stenosis Aortic 137, 138 

Mitral 139 

Pulmonic 14 1 

Tricuspid 140 

Stimulants, Use of 185 

Stomach, Diseases of the 153 to 157 

Stone in the Bladder 181 

Stricture of (Esophagus 151 

Of Urethra 182 

Sugar, Tests for 17, 81 to 84 

Suicide, Cases of 21 

Sunstroke or Insolation 124 

Supra- Renal Capsules — Countenance in Dis- 
ease of 40 

Addison's Disease 118, 181 

Susceptibility to Various Inherited Diseases. .97 to 

106 

Syncope, Causes and Variations 122 

Syphilis — Cachexia 40, 45 

Falling of Hair in 40 

Heredity and Transmission of 102 

Of the Lungs 134 

T 

Tabes Dorsalis 125 

Tables of Height, Weight and Chest-girth. . . . 

16, 49, 50 

Of Height and Weight 53 

Endocardial Heart Murmurs 68, 142 

Epilepsy, Age and Sex 104 

Expectation of Life 31 

Frequency of Hernia 46 

Percentage of Age, Diseases and Deaths. . 30 

Male vs. Female Deaths 34 

British Mortality 44 

U. S. Census Mortality 43 

Race and Mortality 41, 42, 43, 44 

Mortality, Whites vs. Blacks 44 

Pulse Beats and Ages 71 

Respiratory Power 53 

Of Classified Risks 24 

Statistics Appendix. 

Taint— Constitutional See " Heredity." 

Consumptive no 

Taylor, J. M Appendix 1 

Teachers as Risks 22 

Temperaments, Physical 35 

Tests —Urinary, Chemical 17, 77, 87 

Urinary, Microscopical 88 to 97 

Thorax, Pain in the 128 



Throat, Diseases of the 126, 127 

Thrombosis of the Heart 146 

Tongue, Diseases Affecting the 151 

Tonsillitis or Quinsy 127 

Transmission of Diseases 98 to 106 

Collateral Physiological Conditions 98, 99 

Of Single Diseases See ' ' Heredity. ' ' 

Tremors 121 

Tricuspid Obstruction 141 

Regurgitation 140 

Triple-phosphates in Urine 90 

Tuberculosis See Consumption. 

Of the Kidneys 179 

Tuberculous Cachexia 39 

Tumors in the Abdomen 74. 75. 76 

Of the Brain 123 

In the Chest 56, 57, 132 

XX 

Ulcers of the Throat 126 

Of the Stomach 156 

Unmarried Risks 35 

Uraemia 174 

Urea in Urine 85, 86 

Urinary Organs, Diseases of 10, 17, 168 

Urine Examination 17, 77 to 97 

Urinometers 78 

Uterine Diseases 186 



Vaccination 46, 184 

Valves, Location of Cardiac 62 

Valvular Lesions of Heart 137 to 142 

Of Left Heart 136 

Of Right Heart 140 

Varicose Veins 150 

Varioloid 184 

Veins, Varicose 130 

Vertigo, Causes and Varieties 119, 120 

Vital Capacity or Respiratory Power 53 

Voice 60, 6r 

Wasting Diseases, Countenance in 40 

Falling of Hair in 40 

Weight, Height and Chest-girth 16, 47, 49, 50 

Whites, Mortality from Malarial Diseases 44 

Consumptive Mortality 44 

vs. Negro Army Mortality 44 

vs. Negroes, Mortality 42, 43, 44 

Witness, Examiner Signing as a 13 

Witthaus, Prof., Metabolism of Sugar 83 

Worms, Intestinal 159 



Yellow Fever 184 




V 












It 




